Pediatric Coding Alert

Which item is your well-check inclusion appeal pack missing?

Before you throw in the towel on getting paid for a hearing, vision or developmental screening on the same day as a preventive medicine service, try four tactics. 1. Put Modifier 25 on the E/M Service When an insurer considers a screening service included in a preventive medicine service, you can try using modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) with 99381-99385 (new patient preventive medicine service) or 99391-99395 (established patient preventive medicine service). "However, CPT does not require modifier 25 on claims involving a CPT medicine code and E/M service," says Richard Tuck, MD, FAAP, medical director of quality care partners for PrimeCare of Southeastern Ohio in Zanesville. Therefore, you don't technically need modifier 25 when the pediatrician also performs a screening during a preventive medicine service, such as:

• hearing screening (92551, Screening test, pure tone, air only)
• vision screening (99173, Screening test of visual acuity, quantitative, bilateral)
• developmental testing (96110, Developmental testing; limited [e.g., Developmental Screening Test II, Early Language Milestone Screen], with interpretation and report).
 
Some payers may allow payment if you use this method. "We're seeing more and more insurance companies that want a 25 on the preventive medicine service when coding a screening," Tuck says.

Beware: Revisions in CPT 2008 to modifier 59 (Distinct procedural service) put an end to using 59 on the screening to designate it as distinct from the E/M service. Look for details on these changes--and what to do for payers that don't follow suit--in next month's Pediatric Coding Alert. 2. Appeal With CPT Guidelines Take advantage of your CPT manual if you appeal screening with preventive medicine service bundles. CPT considers screenings distinct and does not include them as part of a preventive medicine service, Tuck says. "Your appeal letter should point that out."

Good idea: Indicate that you are attaching supporting documentation showing CPT's non-inclusion of screenings with preventive medicine codes. Include a copy of CPT's preventive medicine services introductory notes with your appeal letter. Highlight the final paragraph (on page 32 of the CPT 2008 Professional Edition), which states, "Immunizations and ancillary services involving laboratory, radiology, other procedures or screening tests identified with a specific CPT code are reported separately. For immunizations, see 90465-90474 and 90476-90749."

Tip: When appealing a vision-screening bundle, also include 99173's entry, which reiterates that the screening is not included in a preventive medicine service. Highlight the second sentence of 99173's parenthetical instruction, which indicates, "Other identifiable services unrelated to this screening test provided at the same time may be reported separately (such as preventive medicine services)" (page 436). 3. Include AAP Support You could [...]