Pediatric Coding Alert
Modifiers Might Be Required for Well/Sick Visit Combos
Question: We billed a well-child checkup and a sick visit on the same day. For the sick visit we billed 99213 (Outpatient office visit), J0696 (Injection, ceftriaxone sodium, per 250 mg) and 96372 (Therapeutic antibiotic administration). The commercial carrier did not pay us for the 96372 because they stated that it bundled into the well child checkup visit (90460). I have never heard of this -- can you advise how to code this service?
Virginia Subscriber
Answer: Unfortunately, you are limited by some Correct Coding Initiative (CCI) edits in how you can report these services together, but the use of modifiers will help you. For instance, CCI bundles 96372 into 90460, but you can separate these edits by appending a modifier.
As this patient’s encounter is described, the appropriate coding would be as follows:
9939X (Periodic comprehensive preventive medicine visit) for the well child exam
99213-25 (linked to separate diagnosis) for the sick visit
96372-59) for the antibiotic administration
J0696 for the product
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