Pediatric Coding Alert

Question: Some insurance companies pay very low rates for E/M codes. I would like to do some bundling before they do. For instance, I would like to bundle the 99391 with a 99212-25 and submit it as a 99215.

Anonymous IL subscriber

Answer: It is incorrect to do this. The infant preventive-medicine-services visit (99391), like other preventive-medicine-services visits, can certainly be billed in addition to a sick-visit (99212), with the modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). There are many circumstances under which this would be appropriate and ethical. Lets say a child comes in for a well-visit and the mother comments that the child has been having headaches on and off for three months. This may require a workup that is more in-depth than the well-visit alone would have been. You need to account for medical decision-making as well. In a situation like that, you would be justified in billing for the well-visit and the sick-visit (although not all insurance companies will want to pay for both).

However, you cannot take a 99212 and make it into a 99215 just because you have done a preventive-medical-services visit as well. This would be fraudulent. When you bill a 99215, you must perform at least two of the following: a comprehensive history, a comprehensive examination, and medical decision-making of high complexity. By contrast, 99212 is a problem-focused visit with straightforward medical decision-making. You cannot exchange a 99391 for a 99215.

Here is a good rule of thumb: Never change a code because you dont like the reimbursement on the correct code. If you dont like the reimbursement, you should renegotiate a better fee or drop the plan. It is true that most of this subscribers insurance carriers are ignoring the modifier -25 and refusing to pay for well- and sick-visits on the same day. You can fight the company on the modifier with letters and copies of the page of CPT that illustrates the proper use of modifier -25. Go ahead and fight the company on the modifier. If you miscode, you will be liable if you are audited.