Wiki Preventative visit, vaccines, and modifier 25

[lmjd]

And so I am starting to get a handful of claims that are not paying the preventative portion of the visit. For example, I bill 99392, 90460, 90686 and 99213-25. The child is here for a well visit but there is a separate and identifiable issue that the physician addresses and treats. Now I am seeing CCI edit denials stating the 99392 and the 90460 are inclusive and getting paid only for the admin, flu vac and the 99213. This is not limited to the flu, it is happening with other vaccines also. Have been doing this a few years now and this is just starting to come up.
Has the guideline changed that you can only use 25 once on a visit and it is always on the E/M code? would there be any other way to modify it?? I have searched for some clear guidelines but don't find anything new. Any help would be greatly appreciated!

 

[HangarPilot]

A -25 modifier is required on the 99392 also. Forget (for a moment) that you are billing a separate 99213. You should have:
99392-25
90460
90686
Because of the 90460, you need a -25 modifier on the E/M.

Now when you need to tack on a second E/M:
99392-25
90460
90686
99213-25
The 99213 also needs a -25 because the CPT coding guidelines say so (to identify it as separate from the 99392).

This works for all of our carriers except for straight Medicaid (straight Medicaid will not accept a -25 on a preventative visit for some reason). Our office put an in-house "edit" in place to check for this so it's not an issue at all for us. But yes, once upon a time if the modifier was left off the preventative visit we got the same results (everything paid but the preventative) and would have to resubmit it with the additional modifier.

In essence, the second E/M always requires a -25, the preventative E/M requires a -25 when required by another code (90460, 96110, etc).