Pediatric Coding Alert

Hint: When billing both well and sick child visit, put modifier 25 on the sick visit code.

Want to collect for both a procedure and an E/M service, or a sick and well visit performed during the same appointment? Then modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) is your friend.

Pediatric practices need to know how to use this modifier properly, or your payer could deny your claim. You can collect prompt payment by avoiding the following four problems that will land your claims on the insurer's hot list.

Problem 1: No Separate E/M 'HEM'

If you report an E/M visit and a procedure together, you not only need to describe the procedure you performed--you must have a separate and distinct E/M evaluation with supporting documentation.

For example: Documentation shows that a pediatrician provides second-degree burn treatment (16020) for a patient on the same day as an office visit, but offers no information about the separate E/M service (such as 99201-99215, Office or other outpatient visit for the evaluation and management of a new or established patient).

Because the physician had to perform an evaluation of the patient before performing the burn treatment, you should be justified in reporting both the E/M visit and the burn care, as long as the services are "significant, separately identifiable" and "above and beyond the usual preoperative and postoperative care associated with the procedure."

Best bet: When using modifier 25, you should remember this maxim: If you don't have a HEM, you can't bill an E/M.

Here, "HEM" stands for "history, exam and medical decision-making." All procedures include some service related to patient evaluation and management, but a separate E/M should include its own HEM.

In other words, the pediatrician needs to determine whether the problem is significant enough to require additional work to perform the key components of the problem-oriented E/M service, or has a time-based service related to significant counseling and coordination of care.

Problem 2: Modifier 25 With Single-Code Claims

Although the news that all procedures contain a minor related E/M service might surprise you, you probably know that modifier 25 submissions require a minimum of two codes. However, auditors often find that not all coders are aware of this, and that they occasionally see modifier 25 on claims when an E/M visit was the only service reported.

Without an accompanying initial service or procedure, you can't have a significant, separately identifiable service, experts say. When submitting claims consisting solely of an E/M code, make sure you don't include modifier 25.

Problem 3: Modifier 25 With Sick and Well Visit

Often times, a patient will present for a physical but you'll discover a problem that must be separately evaluated during the visit. In this situation, you'll report the preventive medicine code (for instance, 99393, 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; late childhood [age 5 through 11 years]) with the diagnosis code V20.2 (Routine infant or child health check). This requires that all of the elements of the preventive visit are met, even though the child is ill.

In addition, you'll report 9921x-25 linked to the diagnosis code for the illness that the pediatrician treated during the visit.

To maximize payment potential, make sure the doctor keeps notes on the two visits separate. One effective way of doing this is to first draw a line at the bottom of the physical-exam sheet. Then document the history, exam and medical-decision making relevant to the illness below this line, or turn the preventive medicine template over and document the separate and distinct E/M visit.

Tip: Be sure the "well visit" and its supporting documentation are easily distinguished from the "sick visit" and its supporting documentation. Also, make sure you have reported thorough and accurate ICD-9 coding wherever possible to strengthen your claim.

Problem 4: Make Sure E/M Is Medically Necessary

If you plan to bill an E/M service with modifier 25, you must ensure that the evaluation is medically necessary. Consider these examples of when the E/M is necessary and when it isn't:

Necessary: "A mother once brought her daughter in for terrible bad breath," says Richard H. Tuck, MD, FAAP, pediatrician at PrimeCare of Southeastern Ohio in Zanesville. "I asked if she had something up her nose, and the mom said, 'No, she would never do that.' So I did an exam and found a big makeup sponge in the child's nose."

In that case, Tuck reported 99213-25 linked to diagnosis of halitosis (784.99), followed by the nasal foreign body removal code 30300 (Removal foreign body, intranasal; office type procedure) linked to diagnosis code 932 (Foreign body in nose).

Not necessary: If the patient had instead presented and the mother said, "My child stuck a bead up her nose," the physician would just look in the nose and remove it, and would only report 30300 with no E/M service.