Pediatric Coding Alert

Often a child comes in for an office visit, and something else in addition to the original complaint surfaces. Can you get reimbursed for both? The answer is yes.

Earaches and cerumen removal. For example, Rose Potter, CMM, office manager for John C. VanPelt, MD, FAAP, Ellsworth, ME, asks: If a child comes to the office for a well child care visit or an earache, and during the exam it is found that he or she needs a cerumen removal, almost all insurance companies deny the claim for the cerumen removal. Is there a modifier I should be using that reflects that an additional procedure is being done that wont cause a rejection?

The answer is to use the modifier 25. You should attach the modifier to the office visit itself. A fourth-level office visit for an earache would be coded 99214-25. Then, make sure you have the correct diagnosis next to the office visit code (381.02 for acute mucoid otitis media). Then, code for cerumen removal (CPT 69210 ), with the diagnosis code (380.4 for impacted cerumen).

Another example: Halitosis and foreign body in the nose. One of the favorite examples of Thomas A. Kent, CMM, office manager for Esther Y. Johnson, MD, FAAP, Dunkirk, MD, is that of the child with halitosis. When the mother made the appointment, she said it was because her child had bad breath. And it was true -- the child had breath that could knock you down from ten feet away, says Kent. It turned out that the cause of the bad breath was some gauze that the child had put in his nose. The gauze, which had putrefied, needed to be removed. The doctor had to do an exam, take a history, and engage in medical decision-making, says Kent. She had to evaluate what was causing the bad breath. So the office visit was coded 99213-25, with a diagnosis of halitosis (784.9). Then, 30300* is used as the procedure code for foreign body removal, with 932 (foreign body in the nose) as the diagnosis code.

* Starred procedures: Note that 30300 is a starred procedure. This means that it is a minor surgical procedure which can be listed with a 25 modifier if significant additional service is provided. From the surgery guidelines: 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.