Handling Same-Day Preventive and Sick Visits: Billing Made Easy
Learn how modifier -25 can help your pediatric practice bill well-child and sick visits on the same day, ensuring accurate reimbursement and transparent documentation practices.
Pediatric Billing & Coding Alert
Preventive-medicine service codes (99381-99397) are designed for asymptomatic patients or those with only minor issues. As soon as a medical problem arises, a more detailed history, examination, and medical decision-making process is required, transitioning the code to a higher office visit category (99201-99215).
For years, many pediatricians have charged a higher office visit code for sick visits than the well-visit code to ensure payment from insurance carriers, as traditional fee-for-service plans often didn't cover well-child visits. However, this practice is considered fraudulent.
Managed Care and Its Impact on Well-Child Visit Coverage
The good news is that well-child visits are often covered with the shift to managed care. However, coverage is typically limited to a certain number of annual preventive visits rather than being paid per visit.
Additionally, pediatricians often face the challenge of coding both a well-child visit and a sick visit on the same day, which requires careful consideration to avoid billing errors and ensure proper reimbursement.
Scenario: Well Visit Followed by Sick Visit
Consider a situation where a child has a good visit in the morning and then returns later the same day due to a fall. This common scenario presents a billing challenge. A biller for Warren Pediatric Associates, the solution is to apply modifier -25 to the office visit code.
Understanding Modifier -25
Modifier -25 indicates that a significant, separately identifiable evaluation and management (E/M) service was performed on the same day as another service. Notably, the symptoms or diagnoses for both visits do not have to be entirely different. For example, in the case of a good visit followed by a visit for a fall, the diagnoses are distinct, making modifier -25 applicable.
Managed Care and E/M Services
Many managed care plans may not cover two E/M services on the same day. However, the CPT guidelines clarify how to handle such situations. In the preface to the preventive-medicine service section, it is explained that if an abnormality or pre-existing issue is discovered during the well visit and it requires additional work for a problem-oriented E/M service, the appropriate office/outpatient code (99201-99215) should be used alongside modifier -25. This ensures proper billing for both services performed on the same day.
Step-by-Step Billing Process
When using modifier -25, follow these steps for accurate coding:
- List the preventive-medicine CPT code for the good visit first, without the modifier, and use the appropriate diagnosis code (V20.2 for routine physicals or V70.3 for sports physicals).
- Do not include any sick diagnosis codes here.
- List the office visit code second, applying modifier -25 to signify that the service is separate from preventive care.
- Include the diagnosis codes for the issues addressed during the sick visit (e.g., the fall).
- Finally, list any additional procedures or lab tests performed.
Communicating with Health Plans
Thomas Kent, former office manager and now president of Kent Medical Management, advises sending the CPT Code guidelines to health plans that are reluctant to reimburse for both visits on the same day. These guidelines on page 32 of the CPT manual provide clear instructions for properly coding two E/M services on the same day.
By following these steps and using modifier -25 appropriately, pediatric practices can ensure they are reimbursed relatively for both well-child and sick visits on the same day, even under managed care plans.
Separate Documentation is Essential for Well and Sick Visits
Accurate and separate visit documentation is crucial, emphasizes Thomas Kent, president of Kent Medical Management. Notes from the two encounters should not be mixed. The sick visit note should be distinct from the healthy documentation to ensure proper billing and reimbursement.
Methods for Documenting Two Separate Encounters
Kent outlines two effective methods for documenting the visits clearly:
- Drawing a Line on the Physical Exam Sheet: One method involves drawing a line at the bottom of the physical exam sheet after completing the well visit. The history and exam relevant to the illness and the medical decision-making are documented below this line, ensuring that the sick visit is fully separated from the visit.
- Referencing Progress Notes: Another option is to return to the progress notes for the sick visit. Here, the history and medical decision-making related to the illness are documented while referring to the well-visit page for the relevant exam results. This approach ensures clarity when distinguishing between the two visits.
Benefits of Clear Documentation
Both methods effectively separate the sick visit from the visit, making it easy to identify the components that support the level of office visit performed. This detailed and organized documentation level is key to winning appeals and avoiding potential billing issues. Pediatricians can confidently navigate the complexities of coding and reimbursement by ensuring that the sick visit is documented apart from the visit.
Educate Payers to Win Appeals for Modifier -25
Many pediatric practices, especially those not working with Medicare, are reluctant to use modifier -25. Despite this, more and more practices are adopting it, particularly as they recognize its importance for billing well-child and sick visits on the same day. However, private payers have not always been receptive to this modifier, leading some practices to avoid using it altogether. The solution is to educate payers about the proper use of modifier -25.
Leverage the CPT Manual to Support Your Case
If private insurers are hesitant to accept modifier -25, practices may find success by sending them a copy of the CPT manual page where the modifier is defined. This documentation clarifies that modifier -25 is legitimate and appropriate for billing a separate evaluation and management service (E/M) on the same day as a preventive visit.
While some practices manage to bill for two visits on the same day without using modifier -25, they often supplement their claims with supporting documentation, such as doctors' notes and a description of the patient's visits. For example, suppose a child receives a well visit in the morning and returns for treatment after a fall in the afternoon. In that case, sending detailed documentation showing two distinct encounters can help prove the need for separate billing.
Understanding Separate Events for Billing Purposes
There is some debate among practices about when modifier -25 should be used. Some believe it is only necessary when a patient leaves and returns on the same day. However, modifier -25 should also be considered when a patient is seen for a good visit and, during the same encounter, a new concern arises, such as the parent bringing up the child's stomachaches. Although both issues may be addressed in a single visit, many of these situations should be billed separately. The timing of the problems during the same visit should not prevent separate billing if the circumstances warrant it.
Use Caution When Billing for Both Well and Sick Visits
The scenario of a well visit followed by a sick visit, such as a child receiving a well visit in the morning and coming back in the afternoon for a fall, justifies modifier -25 and billing for both visits. However, there are times when billing for both a well visit and an office visit may not be appropriate. For instance, a minor issue like a diaper rash that requires a topical treatment, such as Lotrimin, does not meet the criteria for a separate office visit charge.
Criteria for Billing Two Visits
When considering billing for both preventive and office visits, follow these key criteria to determine if modifier -25 is applicable:
- Dealing with a Complex Problem: The issue should involve a more complex diagnosis that requires additional attention beyond the routine preventive care.
- Prescribing Medication: If medication is prescribed during the visit for a non-preventive issue, this indicates a distinct office visit.
- Ordering Diagnostic Tests: If diagnostic testing related to a problem identified during the well visit is needed, it may warrant separate billing.
- Recommending a Consultation: Referring the patient for further consultation or specialist care signifies a distinct medical service, justifying separate billing.
If the issues addressed during the well visit and the additional concern (like a fall) are unrelated, significant, and separately identifiable, both can be billed using modifier -25. The two services must be clearly distinguished.
Managing Parental Concerns and Insurance Practices
A common concern for pediatricians is the fear that parents will be upset if billed for both visits. However, if the insurance company does not reimburse for both services, it is essential not to write off the charges. Pediatricians should bill the parent for the full amount if the insurance company does not pay.
Additionally, practices should be cautious about writing off fees for visits where some insurance companies accept modifiers -25, and others do not. Writing off these charges could lead to discriminatory billing practices, which health plans may take issue with. Instead, pediatricians should accept that they are entitled to compensation for both services, regardless of the insurance plan's policy. This approach ensures fairness across all payers and prevents potential backlash from health insurance providers.
Notify Parents About Billing for Well and Sick Visits
For pediatric practices that wish to bill for both a well-child visit and a sick visit on the same day, it is crucial to notify parents about these potential charges ahead of time. The key is to inform parents of the billing structure change before the pediatrician sees the patient. Clear communication at various levels ensures that parents understand the situation and can make informed decisions.
Written Notification
The first step in notifying parents is to provide written communication. Practices should issue all parents a financial statement outlining important billing policies. This statement should cover topics such as charges for returned checks, late payments, co-pay collection before visits, and specifics about sick and healthy visit billing. This proactive approach ensures that parents are fully aware of the practice’s billing practices.
Here’s an example of how a statement might be worded regarding billing for both a healthy and sick visit on the same day:
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“Sometimes a child is ill on the day their physical is scheduled. When this happens, you have a choice. You may bring your child in to be treated for the illness, and we can reschedule the physical for another day. Dr. Jones recommends this option for more complex issues or problems you wish to discuss at length. If your child has a simple illness like an earache, sore throat, or fever, we can typically treat the illness and complete the physical on the same day. Please note that these are two separate visits and will be billed separately. Kindly notify the receptionist of your child’s illness and let us know whether you prefer to reschedule or have both visits on the same day. Thank you for your cooperation.” |
Additional Notification Methods
In addition to written notices, practices should discuss the billing structure with parents when they schedule the visit, either by phone or online. This way, parents can be informed early and are not caught off guard when they receive a bill. Ensuring parents understand the rationale behind separate billing for well and sick visits will help minimize confusion and ensure smoother billing processes.
Screening Appointments for Well and Sick Visits
When scheduling appointments for well-child visits, the receptionist must screen for additional concerns. As Kent advises, the receptionist should ask the parent, "Does your child have any complaints or illnesses you wish to discuss with Dr. Jones?" This question is key to preventing the well visit from becoming a time to address multiple medical concerns. By prompting this early, the practice can set expectations and effectively manage the time available for each visit.
Offering the Right Option for Sick Visits
If a parent indicates that their child has a complaint or illness to discuss, the receptionist can offer the parent an alternative sick visit slot within the next several days. Most parents prefer to address the issue sooner rather than later, so this proactive approach helps accommodate their needs while keeping the well-visit focused. If a parent insists on combining the well and sick visit on the same day, the receptionist should explain the two options clearly and reiterate that separate charges will apply.
In-Person Screening During the Appointment
The final level of notification occurs when the child arrives at the office. Again, the receptionist should ask whether the child has any additional complaints or issues. If the answer is yes, the parent will be given the option to either reschedule the well visit or continue with the well and sick visit on the same day, understanding that separate charges will apply.
Transitioning to a New Policy
The first year of implementing this policy will likely require some leniency as patients and parents adjust to the new billing structure. However, once it becomes a standard practice, it will be more readily accepted and integrated into the clinic's routine. Establishing clear procedures and educating parents about the process will help ensure a smoother transition.
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