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new patient

  1. Default new patient
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    I have several e/m questions: if a non-medicare new patient receives both preventive and problem oriented visit am I compliant by coding, say, 99386(new patient) and 99203(new patient). Same visit date. Also, I do know modifier 25 goes on the problem oriented visit but don't know why that is. One more question...if a child comes in their well child exam and vaccinations, does the preventive code need a mod 25? Please pipe up if you can help with any of these questions!!!

  2. #2
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    In answer to your first scenario question, using the codes you've used in your example, the codes would be preventative service for new patient (99386) and the appropriate level of service for a follow-up (or established patient) office visit, not a new patient office visit code, because the patient is no longer "new" for this second E/M encounter. The -25 modifier is used to indicate that this is an unrelated evaluation and management service by the same physician on the same day of a procedure or other service...the preventative exam in your example. This helps the second service to bypass computer edits and be considered for payment. Without the -25 modifier, it would be denied because the computer would have already processed a claim for this same patient, by the same physician on the same day.

    In your second scenario patient coming in for visit and vaccinations, no -25 modifier is required on the E/M service code. This combination of billing (E/M encounter/visit with vaccinations) is common and so it was decided that the -25 modifier would not be required for this kind of scenario, nor is a -25 modifier required on the E/M service code, when billing for an encounter in which lab services are also performed.

    I hope that helps!

    MaryAnn Dimitrov, CPC, CPC-H, CCS, CCS-P, AHIMA-Approved ICD-10-CM/PCS Trainer,
    President, Medical Basix
    md@medicalbasix.com

  3. #3
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    Quote Originally Posted by mdimitrov View Post
    In answer to your first scenario question, using the codes you've used in your example, the codes would be preventative service for new patient (99386) and the appropriate level of service for a follow-up (or established patient) office visit, not a new patient office visit code, because the patient is no longer "new" for this second E/M encounter. The -25 modifier is used to indicate that this is an unrelated evaluation and management service by the same physician on the same day of a procedure or other service...the preventative exam in your example. This helps the second service to bypass computer edits and be considered for payment. Without the -25 modifier, it would be denied because the computer would have already processed a claim for this same patient, by the same physician on the same day.

    In your second scenario patient coming in for visit and vaccinations, no -25 modifier is required on the E/M service code. This combination of billing (E/M encounter/visit with vaccinations) is common and so it was decided that the -25 modifier would not be required for this kind of scenario, nor is a -25 modifier required on the E/M service code, when billing for an encounter in which lab services are also performed.

    I hope that helps!

    MaryAnn Dimitrov, CPC, CPC-H, CCS, CCS-P, AHIMA-Approved ICD-10-CM/PCS Trainer,
    President, Medical Basix
    md@medicalbasix.com
    Agreed - I did want to add, though, that some commercial payers may require a 25 modifier on a preventive E/M w/vaccine codes, to override their edits - that doesn't make the denial correct, and it shoud be appealed on principle, alone. But, if the patient has any other kind of service that day that would cause an E/M bundle (for example, a therapeutic drug injection - 96372), the preventive E/M will likely need a 25 modifier, too. The guidelines are vague on which kind of 'significant/separately identifiable E/M services' should be reported w/a 25 modifier (when that guideline is mentioned), so there's room for payers to interpret that as "all E/M services", if they choose.

    Also, some commercial payers may allow both E/M's (sick and well) to be paid as new patient codes, but the majority of them won't. (The logic is, you're only "new" once). As long as you remember that the modifier goes on the sick visit, you should be okay for most claims. Don't be surprised when you're only paid 50% of the allowable for the sick visit - most insurers won't pay 100% for both.

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