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Ace These Pediatric-Specific Modifier 25 Issues by Gau Gan

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Ace These Pediatric-Specific Modifier 25 Issues by
Article Posted: 06/01/2012
Article Views: 190
Articles Written: 223
Word Count: 531
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Ace These Pediatric-Specific Modifier 25 Issues

Hint: While billing both well and sick child visit, you should put modifier 25 on the sick visit code.

Wish to collect for both a procedure and an E/M service, or a sick and well visit carried out during the same appointment? Then modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) is what you need for accurate medical billing.

Pediatric practices are required to know how to use this modifier correctly, or your payer could reject your claim. You can collect prompt payment by side-stepping the following problems that will land your claims on the insurer’s hot list.

medical billing .Problem 1: No Separate E/M ‘HEM’

In case you report an E/M visit and a procedure together, you not only need to define the procedure you carried out--you must have a separate and distinct E/M evaluation with supporting documentation.

For example: Documentation shows that a pediatrician provides second-degree burn treatment (16020) for a patient on the similar day as an office visit, however offers no information about the distinct E/M service (such as 99201-99215, Office or other outpatient visit for the evaluation and management of a new or established patient).

As the physician had to carry out an evaluation of the patient prior to carrying out the burn treatment, you must be justified in reporting both the E/M visit and the burn care, given that the services are "significant, separately identifiable" and "above and beyond the usual preoperative and postoperative care associated with the procedure."

Best bet: While using modifier 25, you must remember this maxim: In case you don’t have a HEM, you can’t bill an E/M.

medical billing . Problem 2: Modifier 25 With Single-Code Claims

Even though the news that all procedures have a minor related E/M service might amaze you, you possibly know that modifier 25 submissions need a minimum of two codes. Though, auditors frequently find that not all coders are conscious of this, and that they sometimes see modifier 25 on claims when an E/M visit was the only service reported.

Devoid of an accompanying initial service or procedure, you can’t have an important, distinctly identifiable service, experts say. While submitting claims containing exclusively of an E/M code, ensure you don’t include modifier 25.

medical billing . Problem 3: Modifier 25 With Sick and Well Visit

At times, a patient will present for a physical but you’ll notice a problem that should be distinctly assessed during the visit. In this situation, you’ll report the preventive medicine code (for instance, 99393, Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/ diagnostic procedures, established patient; late childhood [age 5 through 11 years]) with the diagnosis code V20.2 (Routine infant or child health check). This needs that all of the elements of the preventive visit are met, although the child is ill.

Besides, you’ll report 9921x-25 associated to the diagnosis code for the illness that the pediatrician treated in the visit.

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