Pediatric Coding Alert

Question: We saw a patient on a Saturday morning during our regular Saturday hours for a preventive medicine service, but during the service, our provider diagnosed an acute migraine. We billed for a preventive visit along with a sick visit with modifier 25 and used 99501, but when we billed to UnitedHealthcare Rite Care (Rhode Island Medicaid), they denied payment saying that the 99214 was also included in the preventaive medicine services. How should we have billed for this encounter?

Rhode Island Subscriber

Answer: There are two separate things going on here, which you can break down this way.

Is 99051 applicable in this situation? While you don’t state your office hours, nor the exact time of the service, you can see if your situation applies by looking at the following example.

Suppose your regular office hours are Monday through Friday 8 AM to 8 PM, and Saturday 8 AM to noon, and you see the patient at 2 PM on Saturday, you would use 99050 (Services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed (eg, holidays, Saturday or Sunday), in addition to basic service). However, if you see the patient at 9 AM on Saturday, you would use 99051 (Service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service).

It’s worth noting that 99051 has a relative value unit (RVU) of 0, so payers usually don’t pay it. However, they might if it is for a condition that might require an urgent care visit. So, if a pediatrician provides a service to the patient during the timeframe indicated above, and if that service alleviated the patient’s migraine to the point that the patient did not need to go to an emergency department (ED) or urgent care — a more expensive visit from the payer’s standpoint — then it might pay, on the grounds that the visit to your pediatrician saved it money.

Is the payer correct in saying that “99201-99215 were also included in the preventive medicine services?” In your scenario, you say that the patient was there for a preventive visit and was also treated for the migraine. For the sick visit, your claim for 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity … Usually, the presenting problem(s) are of moderate to high severity. Typically, 25 minutes are spent face-to-face with the patient and/or family.) should be allowed providing your documentation meets the criteria for a level-four visit.

But the purpose of the patient’s visit was for a preventive service. As the migraine was diagnosed during that visit, per CPT® guidelines you can bill for both a preventive and a sick visit. The guidelines state that an “insignificant or trivial problem/abnormality that is encountered in the process of performing the preventive medicine evaluation and management service and which does not require additional work and the performance of the key components of a problem-oriented E/M service should not be reported.”

However, should the visit uncover a significant problem that required additional and separate work — and migraine should rise to that level — then CPT® directs you to report a problem- oriented E/M service from 99201-99215, appending modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to show that the service was distinct from the preventive medicine visit.

As you documented that during the preventive care that your pediatrician addressed and treated the significant problem of the migraine headache, your claim for the preventive visit along with the sick visit billed with the 25 modifier follows coding guidelines.

However, payment is up to the carrier, and some payers will only pay a portion of the visit. So, even though you can report a level-four sick visit without using the exam and using the detailed history and moderate medical decision making (MDM) as the required two of the three key factors, the payer’s thought is that the payment should be less because you have no need to repeat the exam.