Pediatric Coding Alert

Pediatricians lose revenue if they do not bill for minor procedures done during an office visit. They can't always bill for these procedures and the E/M together it depends on the procedure, the reason for the visit, the available codes and the circumstances. Most of the time a minor procedure and office visit can be billed together, says Richard H. Tuck, MD, FAAP, founding chairman and member of the AAP coding and reimbursement committee and the AAP's AMA review update committee (RUC). The physician must perform a significant, separate procedure from the office visit to charge for both.
 
"Generally speaking, when a physician performs a procedure on the same visit as an E/M service, both should be billed using modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) attached to the E/M code," says Joel Bradley, MD, FAAP, CPT adviser for the AAP. CPT states that a different diagnosis is not required for each. In fact, the symptom or condition that prompted the E/M service can be the same as the procedure.
 
Reimbursement may be denied even though a different diagnosis is unnecessary. Be prepared to appeal. Your documentation should differentiate the work for the E/M service from the procedure. Record the office visit and the procedure on two separate notes or pages in the chart.
 
Knowing when to bill an E/M in addition to the minor procedure is demonstrated in eight examples:
 
Note: Add modifier -25 to the E/M code to signify significant, separate work whenever the E/M is warranted.
1. Peak Flow or Spirometry
 Hand-held peak flow readings lack a code because they are included in the E/M. The payer will bundle any provider work associated with a peak flow into the E/M.
 
If you perform complete spirometry with a graphic record, code 94010 (spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation). An E/M service is warranted, Tuck says. 
2. Pelvic Exam
 There is no code for a pelvic exam, so there is no way to bill for it in addition to an E/M service. If, however, a teen-age girl comes in for a well visit and has a medical problem necessitating a pelvic exam, bill for the preventive-medicine service, CPT 99384 (new patient, ages 12-17), 99394 (established patient, ages 12-17), 99385 (new patients, 18-39) or 99395 (established patients, 18-39), in addition to the office visit, 99201-99205, 99212-99215, with modifier -25 appended to the office visit. A routine pelvic exam is included in a well visit. A pelvic exam that addresses a significant medical problem is not bill additionally, Tuck says. (See Pediatric Coding Alert August 2001 for more on [...]