Wiki Well Visit & Sick visit on the same day

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I'm hoping to get some experienced pediatric advice with this situation. We have a multispecialty group and just started with pediatrics also. When a child comes in for a well visit and during the visit the physician discovers he has constipation issues. He obtains an HPI and also send the patient for abdominal xray along with prescribing medication. With our internal med docs they bill a routine exam and if a problem is treated during the exam we are told (as long as the criteria is met for the level asside from the routine) we can bill the sick visit with a 25 modifier. The pediatrician is stating that most pediatric problems are part of the routine exam. Can anyone give me some input on this specialty?
Appreciated!!
 
This is a common problem for me too! It seems every payer treats this diffrently. It seems like most well child vists treat another issue/problem at the same visit. Even if I use the appropriate modifiers I know some payers are going to reject one of the codes! Most payers I am able to appeal these denials. I would check with the payer reps and medical policys with each payer and appeal what you can!
 
If you send me your fx number, i can send you a copy of the aap's recomendation. I advise you purchase 2013 "coding for pediatrics"
by aap. Hope this helps. Lburke cpedc
 
Pediatric well & sick same day

I really appreciate your recommendation and ask you to please fax the material to 845/754-7588. I tried to search for a 2013 aap reference but not sure if it is out yet?
Thank you
 
Would you mind faxing me this information as well...I'd love to see the AAP recommendation. My fax is 423-915-0635 and my name is Leslie.
Thanks!
 
I agree that you need to purchase "Coding for Pediatrics" as it discusses when it is appropriate to bill an additional E/M with a preventive visit. We will bill an additional e/m if the problem addressed is significant enough that it requires additional work by the provider. You do need to use modifier 25 on the e/m code. The scenario you described would warrant an additional e/m code as long as your documentation met the criteria. We normally don't have a problem with denials.
 
I have coding for pediatrics, but could you pls tell me what page these guidelines are on? Thank you!:confused:
 
Assuming you are speaking of the Preventive Medicine Services codes 99381-99397, open your 2013 CPT book to approximately page 35 and read the guidelines listed (pay particular attention to the green print). It still may be payer specific if they will pay for both services (Washington State Medicaid does). I apologize if these aren't the Well Child codes you are referring to and if this information wasn't helpful.
 
The key factor when the child is in the office for a Well Child visit, is the "illness" significant enough to justify additional E & M outside the preventive visit? ie, a low grade fever of 99.4 is probably not enough to justify a separate E & M, but this same fever with cough, runny nose, and wheezing is significant enough to justify the E & M with a 25 modifier, always on the E & M CPT code.

Modifier 25 Fact Sheet http://wpsmedicare.com/j5macpartb/resources/modifiers/modifier-25.shtml

Definition
Significant, separately identifiable evaluation and management (E/M) service by the same physician* on the day of a procedure
*Same physician - Medicare regulation states: "Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician." The same physician concept also applies when the exact same physician performs services.

All E/M services provided on the same day as a procedure are part of the procedure and Medicare only makes separate payment if an exception applies.

Appropriate Usage
Modifier 25 indicates that on the day of a procedure, the patient's condition required a significant, separately identifiable E/M service, above and beyond the usual pre and post-operative care associated with the procedure or service performed.
Use Modifier 25 with the appropriate level of E/M service.
 
I have typically seen modifier 25 used with preventive and sick visit, but interestingly the cci edits do not recommend a modifier. Kerriea may have an interesting point. Technically, preventive is not a procedure, it is an e and m.

Best practice is to have to separate notes when billing for both preventive and sick. However, I have never seen this happen, but providers and practices often insist on billing both when encountered. One medical director I audited for would have providers see the patient for the sick visit if they were sick that day, and then reschedule for the preventive. Her rationale was that the patient should really be well when performing a preventive.
 
Well Visit and Sick Visit Same Day Billing

I have 2 dates of service where the provider is trying to bill for both a well visit and a sick visit. I say there is not enough medical necessity to bill for the sick visit with the well visit even with a -25 modifier.

First is well visit for 15 month old. Reason for appointment is well check. History of Present Illness is Acute: 2 day history of sudden onset of scant amount of clear runny nose, not treated and without additional symptoms. There was no fever and the treatment was humidify room and bulb suction as needed, no change in diet or activity indicated and rtc for worsening new or persistent symptoms. The immunizations were given.

Second is well visit for 18 month old. Reason for appointment 1. 18 month well check 2. Chapped cheeks. History of Present Illness is Extended: seen 9 days earlier for viral illness, all sx resolved and longstanding redness of cheeks in response to many different foods and activities, treated with OTC moisturizer with some improvement. No fever Treatment: 1. Unspecified viral infection, in conditions classified elsewhere and of unspecified site Notes: resolved....normal activity 2. Rash and other nonspecific skin eruption Notes: try calendula ointment bid rtc if persists. Immunization given.

Please help me show the provider these did not justify the 99213 even if he did a review of systems and history. The patient's mom is very upset that she has to pay for the 99239 and 99213.
 
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