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Proper Billing for Combined Sick Visits and Well-Child Visits (Modifier 25)

One of Health Partners Plans’ primary goals is to ensure our youngest members receive the preventive care they need. That’s why we often stress that you should complete a well-child visit when a child has come in for a sick visit. You should to this after determining that the condition, illness or injury that led to the sick visit does not impede the ability to complete a well-child visit and that the child is eligible for the well-child visit, per their Care Gap Report. 

Based on our claims data, many provider offices miss this opportunity. Well-child visits often do not occur or the submitted claims do not accurately capture the rendered services. When services are documented and billed properly, offices can significantly increase revenue. We want to ensure that our providers are reimbursed properly for the care provided.

SUBMITTING PROPER CLAIMS
Your office can submit claims for both a sick visit and a preventive well-child visit for services provided on the same day, provided that the Modifier 25 is added to the claim.

The components of a Well-child Visit, as indicated by the Early Periodic Screening, Diagnosis and Treatment (EPSDT) criteria, are:

  • Health and developmental history
  • Physical exam
  • Laboratory tests (as appropriate for the age of the child)
  • Immunizations (use all visits, preventive and sick, if medically appropriate)
  • Health education and age-appropriate anticipatory guidance (including schedule of care and dental home referral)

Please note: In order to bill for the well-child visit, all components must be addressed. Please refer to the EPSDT periodicity schedule on our website for the complete list of components and to the DHS website (Medical Assistance Bulletin #99-15-07) for a summary of recent EPSDT changes.

Please note the following coding reminders/clarifications:

  • Modifier 25 must be billed in the first modifier position with the applicable E&M code for the allowed sick visit. When modifier 25 is not billed in the first position, the Sick Visit will be denied.
  • Providers can bill the age-appropriate preventive CPT codes (99381-99385, 99391, 99392-99395), and 99461) and a separate identifiable E&M code with the modifier 25.
  • Well-child visits should be reported with the following diagnosis codes: Z00.00, Z00.01, Z00.5, Z00.8, Z00.110, Z00.111, Z00.121, Z00.129, Z02.0-Z02.6, Z02.71, Z02.82, Z76.1, and Z76.2.
  • Appropriate diagnosis codes must be billed for the respective well-child visit and sick visit.

 

Note: Providers must have proper medical record documentation to support the CPT codes and the E/M codes billed. This documentation should be able to be separated into two distinct notes that will support both E/M services billed for the visit.

If you have questions or concerns, call the Provider Services Helpline at 1-888-991-9023.