Resolved Well Visit and regular office visit

[AmberP_3451]

A provider wants to bill a well child and E/M on the same day. The child was diagnosed with Eczema and prescribed two topical creams. The note doesn't distinguish any other part of the visit from the well child. The "skin" portion notes the eczema, and the RX is noted. Would you code this as a level 4?

 

[Alicia]

To address the question of billing for both a well-child visit and an Evaluation and Management (E/M) service on the same day, let's consider the scenario:

1. Well-Child Visit: The primary purpose of the visit was a well-child examination, which would typically be coded using preventive medicine service codes (e.g., 99381-99461).
2. E/M Service for Eczema: During the visit, the child was diagnosed with eczema and prescribed two topical creams. This indicates that a problem-oriented E/M service was performed in addition to the well-child visit.
3. Coding Guidelines:
   • According to CPT guidelines, if a problem is addressed during a well-child visit that requires additional work beyond the preventive service, you can report an E/M code (99202-99215) with Modifier 25 to indicate a separately identifiable service was performed on the same day.
   • However, in this case, the note does not clearly distinguish the E/M service from the well-child visit, which might make it challenging to justify a separate E/M code.
4. Level of E/M Service:
   • If you decide to code an E/M service, determining the level (e.g., Level 4) depends on the complexity of the medical decision-making, the extent of the history taken, and the physical examination performed specifically for the eczema diagnosis.
   • Given that the note does not provide detailed information about the history, examination, or medical decision-making specifically for the eczema beyond the diagnosis and prescription, it might be difficult to justify a Level 4 E/M service without additional documentation.
5. Recommendation:
   • If the provider feels that the eczema diagnosis and treatment required significant additional work beyond the well-child visit, they should document this clearly in the medical record.
   • If the documentation supports a separate E/M service, you could report an E/M code with Modifier 25. However, without clear documentation of the additional work performed, it might not be appropriate to bill a separate E/M service.

How to Bill Preventive and Sick Visits on Same Day

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.

billingfreedom.com