The right time for modifier 25

Key Points

Common sense tells you that immunizations, health screenings, and anticipatory guidance are included in well visits. Checking ears and throat are also included-but diagnosing and treating an ear infection or sore throat is not. So you can bill these separately.

Two notes

The only time both the well and sick visit codes are billed, the coder reports, is if the physician includes two notes, both of which substantiate reimbursement. For example, one note details the comprehensive well visit. And a completely separate note includes all of the components of a full E/M for the problem visit-separate complaint, and two of the following: history, exam and medical decision-making.

Having two histories-one for the preventive visit, one for the sick visit-will help convince payers that you are not double-dipping on the history portion. You know that the two histories are very different, so double-dipping wouldn't be possible-but the payers may not understand that.

The dilemma in the New York pediatrician's office is a result of health plan reimbursement problems-instead of writing off E/Ms, she has chosen to bill only those for which she knows she will be paid.

Rescheduling the well visit

Burgett from Arizona has a different solution. "United Health Care and Cigna do not pay preventive medicine and E/Ms with 25 on the same day," she says. "We have had the patient choose which they want to deal with if they present for both and usually itthe problem visit. Then, we reschedule the well visit."