Coding Same-day Sick and Well Visit
When reporting the preventive visit (well visit) and a problem-focused visit (sick visit) on the same day, you must append modifier 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified healthcare provider on the same day of the procedure or other service to the problem-focused visit code. For example, CMS specifically allows a separate E/M service with its annual wellness visit (AWV), but requires:
… a significant, separately identifiable medically necessary E/M service (Current Procedural Terminology codes 99201-99215) billed at the same visit as the Annual Wellness Visit, (AWV) [must be] billed with modifier -25. That portion of the visit must be medically necessary to treat the beneficiary’s illness or injury, or to improve the functioning of a malformed body member
Note the explicit requirement of documented medical necessity in the guidelines, above. To demonstrate, consider the following vignette, quoted from the AMA’s August 1997 CPT Assistant:
A 33-year-old established female patient presents to the physician’s office for her yearly gynecological examination. During the examination, the physician identifies a palpable, solitary lump in the right breast.
The physician considers this finding significant enough to require additional work and the performance of the key components of a problem oriented E/M service. Therefore, CPT code 99395 [Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 18-39 years] would be reported for the preventive medicine services visit, and an additional code (99212-99215) would be reported for the problem oriented E/M service related to the breast lump.
The appropriate problem oriented level of E/M service should be selected based on the key components associated with providing the problem oriented E/M service. For established patients office or other outpatient visits, two of the three key components (history, examination, and medical decision making) must meet or exceed the stated requirements to qualify for a particular level of E/M service. Modifier -25 would then be appended to the office visit level of service reported, to indicate that a significant, separately identifiable E/M service was provided. The ICD-9-CM diagnosis codes reported should also reflect the services provided.
Remember: When selecting the additional E/M level of service, only the work “above and beyond” that performed as part of the well visit may be counted toward the problem-focused visit. To differentiate the two services, best practice is for the provider to write separate encounter notes (one for the well visit and one for the sick visit).