decisionhealth Newsletters, Coder Pink Sheets - 2004 Issue 12 (December)
Use modifier -25 for 96110 with well-visit only if payer requests it
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Article Overview
This article explains how pediatric practices may approach payment for developmental screening and testing performed alongside preventive visits, with attention to payer bundling, documentation, and differences among insurers and Medicaid programs. It is aimed at pediatric coders, billers, and practice staff who need to understand when payer policies may affect reporting, reimbursement, or patient billing. The guidance addresses common payer reactions, the role of modifier use, and the importance of contract and documentation review.
Why This Topic Matters
Pediatric practices often face denials or bundling edits when screening services are performed during well visits, so understanding payer-specific expectations can affect reimbursement, compliance, and contract negotiations.
Article Sections
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Developmental testing and payer bundling
Introduces the article’s focus on developmental screening/testing during pediatric well visits and the general issue of bundling across payers.
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Payer-specific billing experiences
Summarizes reported experiences from pediatric practices and coders regarding insurer preferences, documentation practices, and differing responses to screening services.
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Documentation, policies, and contract considerations
Covers documentation expectations, references to pediatric exam guidance, and broader considerations related to payer policy and contract language.
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Handling nonpayment and patient billing
Addresses options discussed for services that are not reimbursed, including how payer policy and contractual restrictions may affect write-offs or patient billing.
What You Will Learn
- How pediatric developmental screening services are being handled by different payers
- Why documentation can matter when more than one service is reported at a well visit
- What general payer and contract issues may affect reimbursement or patient billing
- How practices think about bundled versus separately considered developmental testing services
Who Should Read This
- Pediatric coders
- Medical billers
- Practice managers
- Revenue cycle staff
- Pediatricians
- Compliance staff
Codes Discussed
Modifiers Discussed
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