Wiki Well Child Check w/ E&M for problem

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mullman

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I have something I would like to clarify. There’s been mixed messages from our billers on this. I hope you all can enlighten me.

Example: My pediatric provider see a patient for a well child exam. During this well child exam the patient and/or parent mentions an ailment or problem and the child is diagnosed during the exam with an illness/problem.

I say that we bill the preventative exam, add a 25 modifier and pull out the information regarding the ailment to get the E&M code, usually end up with a 99212 or 99213, and bill them together. I have another biller who disagrees and says we should only bill the wellness visit. Our HIM Clinic Coder agrees with me, the providers are confused and now I'm second guessing myself.

Any thoughts to help us come to a conclusion?
 
I agree with you. If you cross out the elements of the wellness visit and the remaining clinical information supports an E&M code, then you can append the 25 modifier and add the E&M code.
 
We are a pediatric provider and this issue comes up quite often because of the population we serve. If the patient is being seen for a well child exam and during the exam we identify an "sick" issue, if the documentation for the sick issue can stand on its own (2 out of 3 for established and 3 out of 3 for new) then we add the E&M code with a modifier 25.
 
You're absolutely correct. I code pediatric charts all day, and as long as the documentation for the additional E/M code can stand on it's own, you can bill it.

- Mike, CPC, CPB
 
maskounes said:
...as long as the documentation for the additional E/M code can stand on it's own, you can bill it.
Click to expand...

Totally agree.

You are essentially saving the patient a trip to the office. For a long time we were hesitant to do this. We would treat the illness and have them come back again for the Well Visit in 2 weeks when they were better.

One word of caution though, when we initially started doing these combined visits we had some upset parents. They had grown accustomed to coming to the Well Visit with their "laundry list" of concerns which we were addressing but not getting paid for. Now that we are coding "correctly" commercial insurances will apply a copy or deductible to the non-preventative E/M.

Parents will call and complain (some even accuse us of fraud) because they've "never been charged a copay for a Well Visit" ... it can take a lot of explaining to make them understand they had a Sick Visit AND a Well Visit. (One of my coworkers even coined the term SWell Visit.)

It has gotten better over time but it was a little ugly when we first started doing it.
 
if the patient presents with a complaint then you cannot perform the well exam. the code description states:
encounter for general exam without complaint, suspected, or reported diagnosis. It must be an issue the provider discovers while examining a "well" patient. Then you may bill an additional office visit and use the dx code for with abnormal finding.
 
Confirming Coding for E&M versus Well Check

Hi,

Just wondering if this article can affect the way we code for E&M versus Well Check:

https://www.aapc.com/blog/35667-icd-10-restricts-same-day-sick-and-well-visits/

Is it still applicable that we code for a well check and an E&M service appended with modifier 25 and still get paid?

Like for example, patient visited the clinic, have a well check (annual exam) then other conditions were also check (HTN, DM, CKD, etc). Is it right to code this as:

Annual Exam
Visit Code - modifier 25

Thanks!
 
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