Primary Care Coding Alert

Family practitioners commonly see their patients for preventive-care visits, but how should they code when the patient also mentions a specific problem during the appointment? Consider a 30-year-old established male patient who comes in for his annual physical exam (periodic preventive medicine, 99395) but while he is in the family doctors office complains of a sore knee. The physician takes the time to examine the joint, questioning how long it has hurt, how severe the pain is and what may have caused it. The family doctor prescribes medication for tendonitis and tells the patient to return in a week for a follow-up. In addition to the preventive-care office visit, the family physician dealt with a specific problemthe sore knee. Accordingly, you also could code 99213 (office or other outpatient visit of low complexity) appended with modifier -25.

Kent Moore, manager of reimbursement issues for the American Academy of Family Physicians (AAFP), says that some family doctors tend to undercode by lumping both services together, while others bill the problem-oriented examination at a higher level than appropriate. To add one more bit of confusion, he says, not all carriers are set up to recognize modifiers. The CPT guidelines clearly state that modifier -25 is a significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service. In short, the modifier is used to indicate services undertaken in addition to an office visit.

Although many carriers interpret separately identifiable service to mean unrelated to the service performed, the Health Care Financing Administration (HCFA) says: A documented, separately identifiable related service is to be paid. We would define related as being caused or prompted by the same symptoms or conditions.

Thomas Kent, CMM, principal of Kent Medical Management, a medical office management and coding consulting firm in Dunkirk, MD, has three rules of thumb for using modifier -25:

1. Attach modifier -25 to the office visit, not a procedure or other service performed.

2. Document the office visit separately from the procedure or other service on the claim form.

3. Dont discount your services. Charge 100 percent for both the office visit and the procedure or other service provided for the problem.

Kent points to several examples that help explain the use of modifier -25. He recalls an incident in which a mother brought her child in for halitosis. Although the cause was a piece of gauze the child had stuck up his nose, the physician didnt know this when she began her exam.