Wiki EPSDT visits Modifiers EP & 25

[jotten]

I am having some difficulty with on of our Medicaid payers, they sent us a provider update stating that we can bill a preventative EPSDT visit with a level 1 or level 2 office visit if diagnosis warranted it. My understanding is that when a EPSDT visit is billed we place the modifers EP & 25 on that CPT code (ie: 99392) when we also preform other procedures (vaccines vision etc) IF the provider also discovers another problem (rhinitis) and does a lower level office visit (per the provider update) we can also bill an E/M visit with a modifier 25.
Both the EPSDT visit and the E/M are being denied as incidental to the vaccine admin. code. My question is can I place modifier 25 on BOTH EPSDT visit AND E/M code or only on E/M and no modifier on EPSDT code?
Example: 99392 EP 25 V20.2 OR 99392
99211 25 460 99211 25
90744 V20.2 90744
90648 V20.2 90648
90471 V20.2 90471
90472 V20.2 90472

All of that is a bit confusing I apologize, but any help given would be GREATLY appreciated!!

 

[OCD_coder]

I would hesitate using a 99211 with any of the services as this is a red flag for many of our carriers. If the provider is seeing the patient, the lowest level they should bill would be a 99212. I refer to the guidelines in the CPT manual that states "Code also significant, separately identifiable E&M service on the same date for substantial problems requiring additional work using modifier 25 and (99201-99215)".

The 99211 really requires no substantial additional work by the provider, this is work performed by the nurse typically. So I would need to see the documentation you have to really support a separate E&M before commenting further. I look for two independent notes that can be reported in separate paragraphs for the 2nd E&M.

 

[sarahjanejones]

Which state? I have worked in IL and AR and the Medicaid programs are very different as far as the billing is concerned.

I can give you an example of how it would be billed in AR:

99392-EP-U2 V20.2 (has to go on an EPSDT claim form so we have to add an "ailment" in our system so it sends correctly)

90648-EP-TJ V03.81 (sent on a regular CMS-1500, no ailment needed)

99212-25 472.0 (sent on a regular CMS-1500, no ailment needed)

I know one of the keys with our system is making sure the level of service, 99212-25, does not go on the EPSDT claim (with the ailment). If it does, it will be denied every time.

I hope this helps and didn't just make it more confusing.

 

[synergen01]

I have some concern with few claims which denied by peach state Medicaid requesting EP modifier for vaccine admin code for patients above 21 ages. Appreciate if anyone can help to identify the specific reason or a guideline.