Wiki Preventive visit with vaccination

sunrise19

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The patient 15 years old has only medicaid insurance comes for preventive visit and flu, gardasil shots.

99394-25
90686 x 1
90451 x 1
90471 x 1
90472 x 1

When I use modifier 25 on 99394 we get paid for 90471, 90472
But If I don't use modifier 25, we don't get paid for 99394
Which one is correct billing : with mod 25 or without mod 25? Please help

Thank you
 
Read the definition of Modifier 25. Does the documentation meet the requirements? Does the documentation support 90471/90472 being reported separately with the 99394? What does the Medicaid manual for the plan you are billing state about preventive and vaccination administration with counseling?

Correct billing would be whatever is supported by the documentation.

90471 hits an NCCI PTP edit with 99394. That's why it is denied without a 25 modifier.
 
You would use the 25 modifier in this instance if the vaccinations were done during the same encounter as the visit itself. This is very common in Peds and IM. If you don't use the 25 modifier then you're not going to be paid for the procedure that was associated with the visit.

In addition, if the provider performed vaccination counseling, then you would be able to use 90460 and 90461 (adjusted to the number of units you need for the vaccine).
 
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