Pediatric Coding Alert

Coding an E/M service with a minor procedure never ceases to stump even the most confident coding experts, so follow five tips to report these services without losing ethical reimbursement and committing fraud.

When a pediatrician provides a separate E/M service and a minor procedure during the same visit, you should bill both services and append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code. Modifier -25 indicates that the E/M is separate and significant to any minor procedure that the physician also provides on the day of the visit, says Shirley Fullerton, CPC, supervisor of HIM (Medical Records) for the Valley Hospital Medical Center in Las Vegas. "The key words are 'separate' and 'significant,' " she says.

Some insurance companies interpret "significant" and "separate" to mean that you must treat something different, says Susan Callaway, CPC, CCS-P, an independent coding auditor and trainer in North Augusta, S.C. "CPT states that this is not necessary, and Medicare does not require a different diagnosis."

For instance, a 3-year-old child cuts his wrist on the edge of a glass table. He is rushed to the pediatrician's office, and has a 2-cm bleeding laceration. The pediatrician examines the injury and determines that no nerve or tendon damage exists. He also inspects the wound for any glass fragments, which he doesn't find, and sutures the laceration.

In this case, you should bill for the laceration repair (12001*, Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]) and the E/M (99212-99215, Established patient office visit) appended with modifier -25. Although there is only one diagnosis open wound (881.02, Open wound of elbow, forearm, and wrist; without mention of complication) the E/M is allowable because the physician performed a separate service to assess the injury's severity. A second diagnosis, however, helps processing claims for an E/M with a minor procedure.

You should also report the E codes, which are for statistics, not reimbursement. For the fall, assign E888.0 (Fall resulting in striking against sharp object) and E920.8 (Other specified cutting and piercing instruments or objects).

Because CPT doesn't require a second diagnosis, many practices want to charge an E/M attached with modifier -25 in addition to cerumen removal (69210, Removal impacted cerumen [separate procedure], one or both ears) with an impacted cerumen diagnosis (380.4) only. "Cerumen removal doesn't pay well," says Barbara Cobuzzi, MBA, CPC, CPC-H, a coding and reimbursement specialist and president of Cash Flow Solutions, a medical billing firm in Lakewood, N.J. When cerumen removal can take 30 minutes or more on both ears, physicians feel that they're not paid adequately. Charging an E/M in addition to the removal, they may reason, helps them obtain "entitled" reimbursement. You should not bill cerumen-removal-only visits this way, Cobuzzi says.

For instance, a patient comes in complaining that he can't hear well. The pediatrician looks in his ear, sees impacted cerumen and removes it, and this is all that is done and all that is documented. Bill the cerumen removal (69210) only, she says. "The physician performed nothing else." You can't support a separate E/M service.

If the ear is examined with otoscopy, however, an E/M is appropriate, says Richard H. Tuck, MD, FAAP, a member of the American Academy of Pediatrics national committee on coding and nomenclature.

But further documentation does not necessarily support billing an E/M. Instead, the physician must show that the service is medically necessary. If the doctor documents a history, examination and medical decision-making that contain nothing remarkable to support the medically necessity of performing that extra work, do not bill the E/M, Cobuzzi says.

If the patient presents for an E/M visit that is separate from and significant to the minor procedure, you should bill both the E/M and the procedure, Fullerton says. For example, a patient presents with wheezing and a fever, and also complains that he can't hear well. The pediatrician performs a level-three history, examination and medical decision-making and determines that the patient has an upper respiratory infection (URI, 465.9). In addition, he removes impacted cerumen. For the service that led to the URI diagnosis, report the appropriate-level E/M (e.g., 99201-99215, New or established patient office visit) appended with modifier -25. For the cerumen removal, assign 69210. Make sure to link the E/M to the URI diagnosis (465.9) and the cerumen removal to impacted cerumen (380.4).

Although reimbursement depends on your insurance contracts, carriers should pay for both services, Fullerton says. "HMO contracts often consider all services provided during a visit bundled or included in the visit or monthly capitation," she says. Practices should not reschedule such services to bill the procedure separately. The U.S. Office of Inspector General may consider such actions "over-utilization," which could trigger an insurance audit, she warns.

If you receive routine modifier -25 denials, create form letters for appeals, but make sure the documentation will support the separately identifiable E/M. Cobuzzi uses separate form letters for new patients and established patients. New patients' needs differ from established patients' needs. When a new patient presents for cerumen removal only, the pediatrician must obtain information, such as patient medications and history, before proceeding with cerumen removal. Therefore, billing an E/M appended with modifier -25 is appropriate even though only a cerumen-removal diagnosis exists.

When reporting multiple diagnoses, make sure to link the appropriate diagnosis to the correct procedure/service. "With electronic billing, assume that most payers will look at the first diagnosis only," Cobuzzi says. If you list the diagnosis that supports the procedure second or third, the carrier may deem the procedure or service medically unnecessary.

For instance, an extrinsic asthma patient presents with difficulty breathing and a fever. The pediatrician performs a history, examination and medical decision-making and administers an inhalation treatment for the asthma. Link the diagnosis for fever (780.6) to the E/M, such as 99215-25, and the asthma diagnosis (493.02, Extrinsic asthma with acute exacerbation) to the inhalation treatment (94640, Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes [e.g., with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device]).

Much of the confusion regarding whether an E/M constitutes a significantly separate service stems from not understanding various payers' global surgical packages. You can't know if the E/M is separate unless you know what the carrier includes in the procedure.

Although CPT and Medicare rules vary, knowing each coding convention can help you understand a carrier's interpretation. CPT includes usual preservice and postservice care with small surgical procedures. For procedures that include the surgical package only, CPT places an asterisk next to the procedural code, which means the service includes the surgical procedure only. Related pre- and postoperative services are not included in the service. You should report all postoperative care and complications on a service-by-service basis.

CPT offers three coding options for a combined starred procedure and visit. When a physician performs a starred procedure that constitutes the major service during an initial visit (new patient), report 99025 (Initial [new patient] visit when starred [*] surgical procedure constitutes major service at that visit) instead of the usual initial visit (e.g., 99201-99205, New patient office visit) in addition to the starred procedure. When a doctor performs a starred procedure during an initial or established patient visit involving significant, identifiable services, report the appropriate E/M code appended with modifier -25 in addition to the starred procedure. When the starred procedure requires hospitalization, list an appropriate hospital visit (e.g., 99221-99223, Initial hospital care) in addition to the starred procedure and its follow-up care. Although CPT does not specify appending modifier -25 to the hospital code in this situation, payers may require the modifier.

For example, a 12-year-old patient presents for a preventive medicine service. During the visit, the girl points out a "bump" on her hand. The doctor examines it and offers to remove the wart with cryotherapy. The patient and her mother agree. The pediatrician applies the liquid nitrogen and informs them that the wart will probably fall off within one week.

The doctor performed a starred procedure (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) at the time of an established patient visit involving a significant, identifiable E/M service. Consequently, you should report the appropriate preventive medicine service (99394, Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunization[s], laboratory/diagnostic procedures, established patient; adolescent [age 12 through 17 years]) appended with modifier -25 in addition to the starred procedure (17000).

CPT also notes that you can bill for a sick visit in addition to the well visit if the problem is significant enough to require additional work to perform the key components of a problem-oriented E/M service. The work involved in diagnosing and treating the wart removal is probably not significant enough to justify an additional E/M.

Medicare uses global surgery indicators, rather than starred procedures, to indicate the care that a procedure includes. For minor procedures, such as cerumen removal, umbilical cord granulation (17250*), and burn dressing debridement (16020*), CMS includes related preoperative and postoperative care on the day of the procedure. Medicare also assigns 10 global days to minor procedures, such as radial head subluxation (24640*), meaning they contain pre- and postoperative care provided on the day of the procedure and 10 postoperative days. Therefore, if you report an E/M in addition to a minor procedure, the E/M must represent work that is not included in the procedure.

Let's look at how Medicare directs coding for the above example of the well visit and wart removal. The 2002 National Physician Relative Value Fee Schedule indicates that 17000 contains 10 global days. To indicate that the E/M is a significant, separately identifiable service, you would have to append modifier -25 to the well visit. Therefore, the coding is the same under either coding system.

Modifier -25 is necessary even when a procedure is not starred, Callaway says. "You need modifier -25 because payers set up their systems to look for a modifier whenever they see an E/M and a procedure to explain why both codes are there," she says. "It has less to do with whether the procedure is starred, and more to do with what the payer views as a minor surgical procedure. Most insurance companies lean toward Medicare's definition of a minor procedure and not CPT's starred-procedure terminology."

Claims involving modifier -25 require clear documentation to inform the carrier that the physician provided a separate service. Documentation should include one section for the history, examination and medical decision-making (HEM) and one for the procedure. You should be able to draw a line between the service and the procedure, Cobuzzi recommends. For minor procedures, such as laceration repair, documentation should include one section for the HEM and one for the repair. When the pediatrician includes the results in the examination section, coders have a difficult time showing that the physician performed the E/M for a separately identifiable reason.