Wiki Modifier 25 - A pediatrician saw a new patient

[Renev]

Hello,

A pediatrician saw a new patient for a well child, figured out some other problems at that visit and administered vaccinations. The CPT ordered are :
99382,99202, 90460,90461 (along with the vaccinations)
My confusion is, should it be :
99382 -25 99382
99202 -25 OR 99202 -25
90460 90460 -59
90461 90461 -59

I would really appreciate some help with this one.

Thank you!!

 

[Renev]

soory, it looked a little confusing after it gost posted.
So, would it be :
99382-25
99202-25
90460
90461

OR

99382
99202-25
90460-59
90461-59

???
Thank you again...

 

[Codex]

I have the same question. I don't think the -59 are correct but the e/m w/-25 is what I wanted to know about. Is it correct to put -25 on both or only on one? Someone that knows please answer. thanks.

 

[MarcusM]

Modifier 25 always goes on the E&M as a "Significant, separately identifiable evaluation and management (E/M) service by the same physician* on the day of a procedure". Be sure to link your diagnosis code for the "sick visit" with the 99212, and the well visit Dx code with the 99382 and vaccinations with appropriate Dx codes. Be advised the clinical documentation for the "sick" visit must support a separate CPT of 99212. And notice I changed the 99202 to an established visit, 99212, instead of a new patient since your well visit is for a "new" patient. Once that patient has been seen and a chart started, then anything else will be established patient.

Modifier 59 Fact Sheet http://wpsmedicare.com/j5macpartb/resources/modifiers/modifier-59.shtml

Definition
Distinct Procedural Service identifies procedures/services not normally reported together, but appropriately billable under the circumstances.

When vaccines are provided as part of a well-child encounter, the ICD-9 guidelines instruct that code V20.2 (routine infant or child health check) includes immunizations appropriate to the patient's age. A code from categories V03-V06 may be used as a secondary code if the vaccine is given as part of a preventive health care service, such as a well-child visit. It's been a few years since I billed immunizations, but I never had to use a 59 modifier.

 

[millbj]

Marcus-

Where do you find documentation to support that you change the OV E/M to established just because you have just seen them for a preventative viist?

I need documentation to support that because I feel it should still be a new patient to the provider and obv a new issue above and beyond the preventative visit.

 

[slik]

MOD 59 on vaccines?

I bill for a pediatric ofc and I have never used mod -59.

Other than that, what sort of insurance do they have? paying or VFC? How old is the pt? Was counseling done by the physician or other qualified health care professional? These things will affect the codes used.

Now as far as the 99212 vs 99202 - are you using the same note? With a shared HPI, ROS, PE, and plan? or does your physician used seperate notes? If it is the same note, I would use a 99202. If it is a seperate note, use a 99212. If it is the same note - be very aware of "double dipping" and don't do it.

I would also be ready to appeal this one. And tell my provider to avoid this if at all possible. Good luck!

 

[ajgibson]

Hello, Just thought I would throw in my 2 cents...

I would do it like this:
99382-25
99212-25
90460
90461

You can not bill 2 new patient codes for a patient. A new patient has not had any services within 3 years, and this patient just received a preventive visit...

I have been billing for 2 pediatricians for a little over 2 years, and we have never used -59 on the immunization administrations.

Oh, and just an FYI, some payers will NEVER pay for an E/M with a prevent... their reasoning is that if the patient is so sick that they need a separate E/M, then they should reschedule the prevent for another day.

Also, patient's or their parents may become upset if they get billed for a co-pay when they went in for the prevent. The physician should be upfront with the patients and let them know that an additional office visit will be billed for, therefore there will be a co-pay associated with it.

 

[KERRIEA]

Check page 94 of "2015 Coding for Pediatrics" from the AAP where it gives instructions in regards to billing both a new p/m code and a new e/m. You can do this, there are just some things to consider before doing so.
Also, we use the modifier on the p/m when we give shots (no 59 mods are needed) and you would also need the 25 on the e/m since you are billing a well with sick. Our payers generally pay for both visits but a copay or deductible could be dropped to the patient for a visit where the patient may not be expecting one. We post signs indicating that this may happen if we treat both a significant problem in addition to a well visit.

 

[sbgill]

Modifier 25

CPT Guidelines for Preventive Medicine Services state "If an abnormality is encountered or a preexisting problem is addressed in the process of performing this preventive medicine evaluation and management service, AND IF the problem or abnormality is significant enough to require additional work to perform the key components of a problem-oriented E/M service, then the appropriate Office/Outpatient code 99201-99215 should also be reported. Modifier 25 should be added to the Office/Outpatient code to indicate that a significant, separately identifiable evaluation and management service was provided on the same day." Also, "the 'comprehensive' nature of the Preventive Medicine Services codes 99381-9937 reflects an age and gender appropriate history/exam and is not synonymous with the 'comprehensive' examination required in Evaluation and Management codes 99201-99350."
Therefore, with regards to the preventive E/M service, you should not be concerned with HPI, ROS and MDM. As for Modifier 59, it is used to "indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day" and for "other than E/M services, that are not normally reported together, but are appropriate under the circumstances." Modifier 59 should be your modifier of last resort.

Here is how I would code your scenario:

99202-25
99382-EP,25
90460-EP
90461-EP

The EP modifier is used to denote services provided as part of a Medicaid EPSDT service and may not be required by all payers. However, it is usually required for state Medicaid/CMO payers. With Georgia Medicaid/CMO payers, we also have to add the EP modifier after the modifier 25 on the Office Visit.

I hope this helps.