Pediatric Coding Alert

Charge 9921x-25 when these elements stand on their own

The next time you're staring at a wart removal chart and debating whether you should also code an office visit, try this litmus test.

If you can highlight a significant, separate service from the wart removal, report an E/M service - and appeal any denials. 

Read the following two entries and decide which one warrants an office visit code.

Hint: Code an established patient office visit plus lesion destruction when you meet these criteria:

1. Documentation contains two of three elements - history, evaluation and/or  medical decision-making

2. These elements are significant and separately identifiable from 17000.

Report Procedure-Focused Notes as 17000

Chart 1: A 15-year-old male comes in complaining of a wart. The plantar wart is small - 3 centimeters in diameter. I use liquid nitrogen to remove the wart. Give patient postsurgery instructions.

Answer 1: In this scenario, you should not report an E/M code (such as CPT 99212 -99215, Office or other outpatient visit for the evaluation and management of an established patient) in addition to the wart removal (17000, Destruction [e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement], all benign or premalignant lesions [e.g., actinic keratoses] other than skin tags or cutaneous vascular proliferative lesions; first lesion]; linked to 078.19, Other specified viral warts).

"The pediatrician doesn't perform a history, evaluation and medical decision-making separate from the procedure," says Steven M. Verno, CMBSI, CMMC, CMMB, NREMTP, compliance director with the Medical Association of Billers. You can't justify 99212-99215 because the physician doesn't perform a separately identifiable E/M service.

Code 2 Separate Elements With E/M

Chart 2: A 12-year-old male presents with complaint of a bump on his foot. He has had the lesion for six months. He has pain when walking and playing sports. The lesion feels better after the patient soaks in the bath tub. Wart has no edema, is 2 cm in diameter and depth, with no redness and no infection. I recommend removal of benign lesion with LO2.

I apply LO2 to remove the lesion. Instruct patient on postsurgery care.

Answer 2: You should code chart two's notes as 9921x-25 and 17000. "When the pediatrician performs a separate history, examination and medical decision-making, you should code the E/M," says Barbara J. Cobuzzi, MBA, CPC, ChBME, CPC-H, president of Cash Flow Solutions Inc. in Brick, N.J.

"I'd probably report 99212-25 in addition to 17000 for such a scenario," Verno says.
 
Dispel Single-Diagnosis Myth

Despite rumors, two diagnoses - such as 382.00 (Acute suppurative otitis media without spontaneous rupture of eardrum) and 078.19 - aren't necessary to bill an E/M in addition to wart removal. "More than one diagnosis will help support a separate E/M, but anytime the pediatrician performs and documents a significant, separate E/M apart from the procedure, you may code the service," Verno says.

Example: In the above chart note describing the 12-year-old boy, you would report the service even though you would use the same diagnosis for both the procedure and the E/M. For a plantar wart, you would link both 9921x-25 and 17000 to 078.19.

Better method: Look for two of three elements. If documentation shows a full history, a procedure-related exam, and medical decision-making separate from the wart removal, you should report the E/M.

The separate medical decision may involve diagnosing the wart and deciding to remove it. "The MDM could be the pediatrician deciding whether to send the patient home with instructions for removing the wart using an over-the-counter compound versus performing the wart removal in the office using LO2," Cobuzzi says.

Fight for Modifier -25 Payment

When the E/M service can stand alone, you should use modifier -25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service). Make sure you attach the modifier to the service code (such as 99212), not to the procedure code (17000).

Payment: Just because documentation supports 9921x-25 doesn't mean you'll receive reimbursement on the E/M. Payment depends on the insurer.

"If documentation justifies billing an E/M, I fight the payer for reimbursement," Verno says. "I'll send the notes highlighting the separate history, examination and/or medical decision-making."

Tip: Include supporting information, such as CPT and the National Correct Coding Initiative (NCCI). In a cover letter to the insurance company representative, explain that per CPT and NCCI, the insurer shouldn't include the E/M with the procedure. "I challenge the payer to show me where the bundle exists or else to reimburse the service," Verno says.