Pediatric Coding Alert

HCFA has temporarily suspended edits introduced in version 6.3 of the national Correct Coding Initiative (CCI) that bundled more than 800 procedural codes with 66 evaluation and management (E/M) services. The suspension, issued Jan. 26, 2001, is retroactive to Oct. 30, 2000, the effective date of the 6.3 edits.

HCFA initially argued the edits were designed to prevent the practice of physicians reporting an E/M service code for the inherent evaluative component of the procedure itself. As a basis for its policy, the agency reasoned, Because every procedure has an inherent E/M component, for an E/M service to be paid separately, a significant, separately identifiable service would need to be documented in the medical record. The bundling of E/M codes with diagnostic and radiological procedures required coders to append modifier -25 (significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to receive separate payment for the E/M service.

Although the CCI applies to Medicare and pediatricians collect few Medicare payments commercial insurance companies are adopting the CCI bundles as well, notes Terri Salus, health policy assistant with the American Academy of Pediatricians Division of Health Care Finance and Practice.

HCFA is reviewing the edits and may reinstate many of them as early as July 1, 2001. Before reintroducing the edits, however, the agency claims it will strengthen efforts to educate physicians and its own carriers about the appropriate use of modifier -25 and what constitutes a significant, separately identifiable E/M service, says Linda S. Dietz, ART, CCS, CCS-P, coding specialist with CCI.

Regardless of the suspension, pediatricians should continue to attach modifier -25 to any significant, separately identifiable E/M service performed on the same day as a diagnostic or radiological procedure. Procedure codes for nebulizer treatments 94640 (nonpressurized inhalation treatment for acute airway obstruction) and 94664 (aerosol or vapor inhalations for sputum mobilization, bronchodilation, or sputum induction for diagnostic purposes; initial demonstration and/or evaluation) for example, were among those included in the bundles, and the suspension does not mean pediatricians may automatically bill an E/M service when they perform a nebulizer treatment. Rather, they must document that a significant and separately identifiable service was performed during the office visit to bill for an E/M service.

Claims for significant, separately identifiable services submitted between Oct. 30, 2000, and Jan. 26, 2001, that were rejected due to the edits may be resubmitted with modifier -25 attached.