Pediatric Coding Alert

The -25 modifier has a bad reputation for not being reimbursed by some insurance companies, but its the answer to many of the problems encountered by pediatric coders. Take catheterization to obtain a clean-catch urine sample. The CPT code for this is 53670 (but dont be afraid to use 53675 if an infant or young child is uncooperative and the procedure is difficult as a result).

But a real problem arises when the office visit isnt paid for. It is quite rare that a child just comes in to be catheterized, without any exam, history, and medical decision-making. And that is what the office visit is for.

Anita Mazin, office manager for Robert Biener, MD of Highland Park NJ, writes concerning catheterization. If you have a child who is catheterized to get a urine sample for a fever of unknown origin, and you bill for the office visit and catheterization, many insurance companies consider the catheterization as a surgical procedure and will not pay for the office visit. What should we do?

Catheterization is a starred procedure, which means that it is a minor surgical procedure that can be listed with a -25 modifier, providing you have done something else in addition. From the surgery guidelines to CPT: When the starred procedure is carried out at the time of an initial or other visit involving significant identifiable services (e.g. removal of a small skin lesion at the time of a comprehensive history and physical examination), the appropriate visit is listed in addition to the starred procedure and its follow-up care.

If the child is there with a fever of unknown origin, and the doctor needs the catheterized urine sample and doesnt do anything else, then you can only charge for the surgical procedure, says Debbie Abbott, billing supervisor for Pediatric Associates, a seven-pediatrician practice in Newark, DE. But if you have to do something else, then you can use the catheterization code along with the office visit code, she says. You need to use the -25 modifier under such circumstances.

(Tip: Remember to put the -25 modifier on the office visit, not on the catheterization.)

For example, sometimes a pediatrician decides to do a catheterization during a well visit, says Abbott. Weve had to catheterize babies at health maintenance visits, she notes. In these cases we use the -25 modifier."

(Note: Abbott gets pretty good results with the -25 modifier for combining well visits and office visits: 30 to 40 percent are paid right away. No, its not 100 percent. But its a lot better than getting paid nothing, which is what shed get if she didnt use the -25 modifier.)

In addition to well visits where a catheterization needs to be done, you can also charge an office visit if there are problems other than UTI that you are considering. For example, if you need to rule out hepatitis, you could bill for an office visit as well as the catheterization, offers Abbott.

Make sure your pediatricians know that they cant charge an office visit along with catheterization alone, says Abbott. If they automatically bill a 99213 every time they do a catheterization, with no supporting documentation for other, unrelated and significant problems, then it will not be reimbursed, and the practice will have to write it off. (The practice will, however, usually still get paid for the catheterization.)

However, in almost all instances, when a pediatrician performs a catheterization, an office visit is appropriate as well. Again, it is only when the patient only gets catheterized that only that procedure code should be used.