Pediatric Coding Alert

Question: In reference to billing a preventive visit for a physical with an office visit and using a modifier -25, we have been billing these cases to our major HMOs and PPOs. Most have paid for both services, but one insurance company has told us that this policy is incorrect. They are stating that if a child comes in for a physical and we use an office visit with a modifier, they place the modifier (office visit) as the main office visit and deny the preventive visit and are having the children come back for a full physical again even though our pediatricians have done the physical. What is correct?

New York Subscriber

Answer: You are correct. Insurance companies may not decide which code is to be placed where. When filing an appeal you should include copies of the CPT book with the description of the -25 modifier (significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) and seek aid and assistance from the local chapter of the American Academy of Pediatrics (AAP). It is very helpful and certainly wants to see that the insurance companies recognize the proper rules for coding. Take the appeal to the highest level of the company that you possibly can.

Call ahead of time and ask for the claims managers name as well as the regional director for claims. Send a copy of the appeal to the patients also because they can act as a liaison and be more effective with the insurance company after all, they are the ones who pay the premium. Finally, contact the American Medical Association (AMA) coding hotline and ask for a written interpretation of the -25 modifier. This also should accompany the appeal. Another option is to have separate visits, as the insurance company seems to suggest. But this is not an efficient way to provide medical care.