Pediatric Coding Alert

If you perform these services, go beyond the E/M codes to boost your revenue.

Although the E/M codes are the bread and butter for pediatric practices, that doesn’t mean your procedures should always be rolled into your E/M services. In reality, you can generate more revenue if you report procedure codes for the following ten services that pediatricians commonly provide in their offices.

1. Circumcisions. For circumcisions performed in the office on a newborn, you should bill 54150 (Circumcision, using clamp or other device with regional dorsal penile or ring block). You should report any additional and separate evaluation and management work with an office visit code appended with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service).

Example: Suppose a nine-day-old child who lost weight in the hospital is brought in three days after discharge for a weight check, examination and circumcision. For the examination, you should assign 99213-25 linked to diagnosis code 783.21 (Loss of weight). For the circumcision, report 54150 with a diagnosis of V50.2 (Routine or ritual circumcision).

If you perform the circumcision on a patient older than 28 days, report 54161 (…older than 28 days of age) instead.

2. Nursemaid Elbow Treatment

You can code for the treatment of nursemaid elbow with 24640 (Closed treatment of radial head subluxation in child, nursemaid elbow, with manipulation). Pediatricians usually report an E/M service in addition to the treatment.

Why: The pediatrician doesn’t just pop the radial head subluxation into place. He has to take a history, examine the patient and then make the medical decision that the condition is a suluxed radius and not a fracture or other injury.

To indicate a significant and separate E/M, you should append modifier 25 to the E/M service code (such as 99212-99213, Office or other outpatient visit for the evaluation and management of an established patient ...).

3. First Degree Burn Treatment

Your pediatrician may be accustomed to bundling all first-degree burns into E/M visits; although this is common for simple sunburns that don’t require any treatment, it may not be for all burns. If your physician provides local treatment to the patient’s burn, choose 16000 (Initial treatment, first degree burn, when no more than local treatment is required) for the encounter.

Watch for: A first-degree burn usually only reddens the skin. The patient might have some swelling and mild blistering, but this is normal and usually resolves quickly. Treatment of a burn categorized by 16000 would include use of topical medication, such as a gel anesthetic. The physician might also apply bandages to the burned area, but first-degree burns rarely require more than an application of cream to soothe the skin.

In some situations, the physician might provide both an E/M service and local treatment of the patient’s burn during the same encounter.

Example: An established six-year-old patient visits your office with a light bulb burn on her right hand. The injury is red, swollen, and non-blistering. The patient says the redness worsened overnight. The pediatrician performs a problem-focused exam and finds that the palm is erythemous, swollen, and hot. He applies sterile gauze over the burn and surrounding non-burned tissue, using tape to secure the bandage. He advises the patient to continue covering the burn with gauze, but to keep the tape off any burned areas. He also tells the patient to keep the burn clean and away from oils. The physician’s exam qualifies as moderate medical decision-making.

In this instance, you can report both an E/M and a burn treatment code. On the claim, report 99212 for the E/M with modifier 25 to show that the E/M and treatment were separate services. Also include 16000 for the treatment.

4. Use Repair Code for Laceration

When a pediatrician closes a simple skin wound, insurers can pay over $110 for the repair. The catch is you have to use the appropriate closure code, such as 12001 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.5 cm or less) or 12011 (Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less).

Once again, you should report an office visit code along with the wound repair code, if the pediatrician performs a significant and separate E/M service evaluating the trauma. You’ll append modifier 25 to the E/M code because the closure codes 12011 and 12001 have zero global days.

Remember: You should count wound closure using Dermabond as suturing. But a Steri-strips repair is not a separately billable service and is included in the E/M code.

5. Always Bill Antibiotic Injection

If a sick child requires a therapeutic injection, you can code for the administration with 96372 (Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular). For instance, to avoid hospitalizing a patient who has pneumonia (such as 486, Pneumonia, organism unspecified), a pediatrician orders a Rocephin shot. You would report 96372, plus J0696 (Injection, ceftriaxone sodium, per 250 mg).

Tip: You should charge an office visit (such as 99212-99215) in addition to the injection administration if the documentation supports it. Giving the shot is not part of the E/M.

6. Bill Catheterization With 51701

Urine catheterization (51701) is another well-paying procedure that pediatricians often forget to code separately.

You should code a urine catheterization with 51701 (Insertion of non-indwelling bladder catheter [e.g., straight catheterization for residual urine]). To get payment for the E/M that led to the decision for the procedure, make sure to link the signs or symptoms, such as fever (780.6), to the E/M, and link the definitive diagnosis (such as urinary tract infection, 599.0, Urinary tract infection, site not specified), to the catheterization. Remember to append modifier 25 to the associated E/M code.

7. Report Cerumen Impaction Removal Plus Separate E/M

An established patient presents with signs of an upper respiratory infection and on examination has cerumen that the pediatrician has to remove—but if you code just 99212-99215, you could be missing out on an additional $50.06 – 69210’s Medicare-equivalent payment.

Lesson learned: Depending on the documentation, you can often report cerumen removal (69210, Removal impacted cerumen requiring instrumentation, unilateral) in addition to a significant, separately identifiable service. Your ICD-9 codes will help you decide whether to code the E/M because you should have separate diagnoses for the two codes. Otherwise, payers will include the E/M with the cerumen removal.

For instance, a child has a bulging ear drum, but an impaction prevents the pediatrician from examining the ear drum so the pediatrician uses instrumentation to remove the cerumen to visualize the ear drum. You would link the cerumen removal code (69210) to the impacted cerumen diagnosis (380.4, Impacted cerumen) and the office visit (99212-99215 with modifier 25) to the middle ear-related diagnosis, such as otitis media (382.00, Acute suppurative otitis media without spontaneous rupture of ear drum).

Keep in mind that cerumen removal using irrigation is not a billable service for impacted cerumen—it is included in the E/M code.

8. Bill spirometry with pre- and post-bronchodilator

If a pediatrician performs spirometry, the procedure choice for most pediatricians is 94010 (Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation).

Scenario: An established patient presents for a follow-up visit after an episode of respiratory distress with wheezing where she needed a nebulizer or inhaler treatment. The pediatrician evaluates the child’s respiratory status, including spirometry and discussing further management. You report 94010 along with an E/M code for the office visit; the child’s significant subsequent management merits 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical decision making of moderate complexity ...). Although not required, a 25 modifier will typically be necessary for prompt payment.

Sometimes a single treatment or test is enough, but if the pediatrician wants more information, she may administer a simple spirometry test, treat the patient with an inhaled bronchodilator, and conduct a follow-up spirometry test. This pre/post test approach is useful in establishing an asthma diagnosis. For that type of test, you’ll report 94060 (Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration) with modifier 25 appended to the appropriate E/M code.

9. Lab Tests

When you perform a preventive visit, you cannot typically bill for the pediatrician’s work ordering lab tests as well. However, if your practice performs those tests in-house, you can separately bill for them along with your preventive medicine code.

Example: For instance, if the physician runs a lab test to check the patient’s hemoglobin, you can report 85018 (Blood count; hemoglobin) and also bill for obtaining the specimen (36416, Collection of capillary blood specimen [eg, finger, heel, ear stick]). Again, modifier 25 may be required by the payer on the preventive medicine code.

10. ECGs

Suppose the pediatrician obtains a patient and family health history and performs a physical exam focused on cardiovascular disease risk factors, then decides to order an electrocardiogram (ECG) to further assess the patient before treating him with drugs for attention deficit hyperactivity disorder (ADHD, 314.01). Although you may be tempted to bundle the ECG into the office visit code, you would not get paid for the work you are doing.

You should bill the global code (93000, Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report) when your pediatrician performs and interprets an in-office ECG and documents his findings. If the patient goes to the hospital for the ECG and the pediatrician still provides the definitive interpretation/report, bill 93010 (... interpretation and report only) for the professional component.