Pediatric Coding Alert

When a child is in for a well visit and also has a problem that the pediatrician knows justifies an office visit, how can your pediatric practice be reimbursed for both? Can you bill for otitis media discovered in the course of a well visit? Or must the problem be more extensive? Sajjad Iqbal, MD, a pediatrician in practice in Ridgewood, N.J., has had success getting paid in these cases by using modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

Pick Your Battles

Early on in the well visit, says Iqbal, he gets a sense of whether there is going to be a sick visit as well. I usually wont use modifier -25 for cases that are small, such as otitis media at the time of a well visit, he says. This is partly a matter of choosing your risk. The insurer, if it will pay only for one of the visits, will pay for the lower-paying service. So if you bill a well visit with, for example, a 99212-25, you risk losing the fee for the well visit and getting paid only the small fee for the CPT 99212 . You run a risk just by filing, he says. So the key is to pick your battles. Only use the modifier -25 with cases that are truly worthy of it, bearing in mind that most private payers simply refuse to honor the modifier -25 at all. But Iqbal has had some success getting modifier -25 paid. And in some cases, he is still fighting. Here are his test cases.

Case #1: An established patient came in for a well visit. During the exam, Iqbal discovered that the patient was severely anemic. The patient turned out to have severe iron-deficiency anemia (280.1)but the pediatrician didnt know that at the time. The pediatrician spent a lot of time on the visit, ordering lab tests and, in general, doing a lot more for this acute problem than normally would be done during a well visit. Iqbal billed a 99214-25, as well as the well visit. The payer, Oxford, denied the sick visit but paid for the well visit (in a departure from the standard HMO response to the modifier -25, which is to pay for the sick visit, but deny the well visit).

Iqbal contacted Oxford and was told that their policy was not to honor modifier -25. So I wrote to the CEO, who used to be the medical director, says Iqbal. I explained that there was extensive extra work involved. I sent a letter, plus the documentation in the chart, the documentation of my time, a copy of [...]