Wiki Billing Well Child Visit with Sick Visit

[dpaine01]

I have a practice that bills an E/M for a sick visit (99214) and then bills the well-child check (99391) for the same visit. The 99214 is submitted with modifer -25. Many insurance companies combine the two services and the office wants the claim appealed. Is there any documentation anywhere that would support billing these together?

 

[cynthiabrown]

check the guidelines in your CPT book

 

[jewhipke]

Medicaid guidelines

According to Medicaid guidelines, a separate E/M can be billed in addition to the health check if additional work needed to be done aside from the health check and the condition(s) was/were severe enough to justify this separate work, but you can only charge a level 1 (99211) or 2 (99212) for established patients, level 2 is the highest level, in additional to your reported health check, or for a new patient a level 1 (99201).
We also were advised that in the medical record it should be clearly defined what the additional workup entailed and we either should create a separate office note or, if documentating in the encounter note for the health check, have a separate section, i.e. at the bottom of the health check section, where everything regarding the sick encounter is listed and what was done.

Hope this helps!