Question:
We have a Medicaid patient that came in for a ten year-old physical and was found to be sick, so we would like to append modifier 25 to report the well turned-sick visit. Is that accurate?- Virginia Subscriber
Answer:
Yes. In this situation, you’ll report 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 requires that all of the elements of the preventive visit are met, even though the child is ill. In addition, you’ll report 9921x-25 (Office or other outpatient visit for the evaluation and management of an established patient; Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) linked to the diagnosis code for the illness that the pediatrician treated during the visit.
To maximize payment potential, make sure the pediatrician keeps notes on the two visits separate. One effective way of doing this is to first draw a line at the bottom of the physical-exam sheet. Then document the history, exam and medical-decision making relevant to the illness below this line.
Tip: Be sure the “well visit” and its supporting documentation are easily distinguished from the “sick visit” and its supporting documentation. Also, make sure you have reported thorough and accurate ICD-9 coding wherever possible to strengthen your claim.
