Pediatric Coding Alert

Gain the confidence to code -- or not code -- an E/M service with a minor surgery by taking this test.

Encounters for splinter removal and laceration repair both seem like plausible times to also bill an office visit for preprocedure work. But you know that coding an E/M service isn't automatic: it must be medically necessary and address key components of history, physical examination, and medical decision-making or be based on time spent in counseling and/or coordination of care. Test your coding against these expert-answered scenarios.

If you know the wart-service rule of thumb, you'll be able to correctly code this scenario:

Question 1: A mother points out a spot on a child's hand, which you identify as a wart. After the mother authorizes the procedure, you remove the wart. Should you code an E/M with the wart removal?

Answer 1: Yes, says Richard Lander, MD, FAAP, pediatrician with Essex-Morris Pediatric Group in Livingston, N.J. "When you have to evaluate a spot to get to the diagnosis, you should code the E/M service and the procedure."

He suggests coding the above scenario with a low-level E/M service, such as 99212-25 (Office or other outpatient visit for the E/M of an established patient, which requires at least two of these three key components: a problem-focused history, a problem-focused examination; straightforward medical decision-making ...; Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service), and 17110 (Destruction [e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement], of benign lesions other than skin tags or cutaneous vascular lesions; up to 14 lesions).

Rule: But if the patient returns with another wart that you remove (17110), you shouldn't code an associated E/M, Lander says. "You already know the diagnosis (such as 078.19, Other specified viral warts), so no E/M service code (e.g., 99212-25) would be warranted."

The same "diagnosis known = no E/M" rule applies in another situation. "If the mother comes in having diagnosed the wart herself, you confirm the diagnosis and treat it, coding an E/M service becomes less medically necessary," says Richard H. Tuck, MD, FAAP, a pediatrician at PrimeCare of Southeastern Ohio. "It definitely can be a gray area."

Although CPT doesn't require different diagnoses to report an E/M service in addition to a procedure, this is a good indication of when an established patient office visit (9921x-25) is appropriate with intranasal foreign-body removal (30300, Removal foreign body, intranasal; office type procedure).

Question 2. Suppose a nanny brings a toddler in because the child stuck a bead up her nose and the nanny can't get it out. Should you report an E/M service plus the foreign-body removal?

Answer 2: "Probably not," Lander says. If you don't have to perform a significant and separately identifiable E/M service to identify the problem, 9921x-25 is inappropriate.

Exception: When the problem isn't immediately identifiable and requires a workup, you can justify coding an E/M service.

"A patient might present with a complaint of halitosis, and from the evaluation you discover an intranasal bead," says Richard H. Tuck, MD, FAAP, a pediatrician at PrimeCare of Southeastern Ohio. In this case, because the E/M service is significant and separately identifiable from the foreign-body removal as indicated with different ICD-9 codes -- 784.99 for the halitosis, and 932 for the nasal foreign body -- you should report 9921x-25 in addition to 30300, he says.

Make sure to link the E/M service (such as 99212-25) to the complaint of halitosis (784.99) and the foreign-body removal (30300) to the reason for the procedure (932).

Apply the same separate-diagnosis rule to encounters involving four nail procedure codes.

Question 3: Should you code an E/M service in addition to these?

• 11720 -- Debridement of nail(s) by any method(s); one to five
• 11730 -- Avulsion of nail plate, partial or complete, simple; single
• 11740 -- Evacuation of subungual hematoma
• 11900 -- Injection, intralesional; up to and including seven lesions.

Answer 3: You should report an E/M service in addition to 11720, 11730, 11740 and/or 11900 if "you do something else," Lander says. Otherwise, report the nail procedure code "in lieu of the E/M service," he says.

The above scenarios indicate that you should code an E/M service in addition to a procedure when the history, examination and medical decision-making are significant and separately identifiable from the work involved in the procedure. See if you can make this distinction in the following scenario:

Question 4: During an established patient preventive medicine service, you notice that a newborn's umbilical stump is seeping. You apply silver nitrate to the stump, performing cauterization of an umbilical granuloma. You code:

A. 99391 -- Periodic comprehensive preventive medicine reevaluation and management of an individual É infant (age younger than 1 year)

B. 17250 -- Chemical cauterization of granulation tissue (proud flesh, sinus or fistula), 99391-25

C. 17250

D. 99214 -- ... a detailed history; a detailed examination; medical decision-making of moderate complexity É

Answer 4: B. "Use 17250 and the E/M code for the well check (99391-25)," Lander says. Make sure to append modifier 25 to the E/M service code that addresses the work performed in evaluating the problem, which is then treated with the appropriate procedure.