Pediatric Coding Alert

Removing even one splinter from a child isnt easyand removing more than one is that much worse. Its a time-consuming process, and children, for some reason, are drawn to splinters like magnets. Takashi Yoshida, MD, of Sunnyvale, CA, writes to ask how to code for multiple splinter removal using a topical anesthetic such as EMLA cream.

We use the incision and drainage codes, says Pam Almandinger, billing specialist for the Pediatric Center, a six-pediatrician, one-nurse practitioner practice also in Sunnyvale, CA. The code Almandingers practice uses is CPT 10120 (incision and removal of foreign body, subcutaneous tissues; simple). This is a starred procedure, meaning that the code is for the surgery only, so technically you can use an office visit as wellbut only if you are doing more than just removing splinters. (See the box on this page for CPT verbiage on starred procedures.)

If the child was playing outside in the Southwest and had a run-in with a cactus, and you arent doing anything else but taking out those splinters, I wouldnt bill for anything but the 10120, the billing specialist says. But if the splinters have been in for a few days, or if an infection is setting in, you can bill for an office visit as well. This is because of the extra medical decision-making involved. Likewise, if, when you are removing the childs splinters, the mother mentions that she thinks the child might be getting an ear infection, and you do an exam for that as well, you can bill for an office visit in addition to the 10120, says Almandinger.

Is a modifier necessary? We always use modifier -25 when we use 10120 with an office visit, the billing specialist reports.

While Almandinger has never had any problems with insurance companies paying for 10120it has never been necessary to send doctors notes, and the claims get paid readilyone mother did complain about this code recently. Not that the mother was a coding expert, but the insurance policy happened to have a surgical deductible. That meant that the mother had to pay out of pocket for the office visit. She said that since we didnt use a scalpel, it couldnt be surgery, says Almandinger. But we use this code anytime we have to go beneath the skin for the splinter, even if its just with forceps. If the splinter is sticking above the skin and can be pulled out with tweezers, for example, you would only use an office-visit code. But if the tweezers go beneath the skin, thats 10120, opines Almandinger.

The problem with reimbursement for splinter removal is that it can take so much time to remove splinters from a child because of the cooperation factor. But remember, even if you spend 45 minutes removing splinters from one patient, you cant select the level of office visit based on time aloneunless 50 percent of the time spent with the child or parent is spent on counseling (not likely to be the case with splinters).

Reimbursement rates are generally higher for code 10120 than for office-visit codes. The highest fee we get for 10120 is $120, and the average is $85, Almandinger reports.

Diagnosis Coding

For the diagnosis code, Almandinger uses the section on open wounds (870 through 897) in the ICD-9, and selects the appropriate site. You would use the fourth digit indicating complications (that would be the foreign body). For example, a splinter in the hand would be coded 882.1 (open wound of hand except finger(s); with major infection, delayed treatment or healing, tissue loss, or with foreign body). A splinter in the finger would be coded 883.1 (open wound of finger(s); with major infection, delayed treatment or healing, tissue loss, or with foreign body).

Thomas Kent, CMM, president of Kent Medical Management, Dunkirk, MD, says that as an alternative you can use the superficial injury codes. These are 910 through 919. For a splinter in the finger, for example, you would use 915.6 (superficial foreign body [splinter] without major open wound and without mention of infection) or 915.7 (superficial foreign body [splinter] without major open wound, infected). These could be used either in addition to the diagnosis codes listed above, or if you are only billing an office visit and not the incision and drainage codes.

EMLA Cream

As for the supply code for the EMLA cream, which doesnt yet have an HCPCS code, Almandinger uses A4649 (surgical supply, miscellaneous). The insurance companies Almandinger works with told her to use this code, and it is working. She has to submit an invoice with the claim form, and the managed care companies pay whats on the invoice.

Tip: Almandinger uses this same code for Dermabond, as per the insurance companys request. And for Dermabond, she doesnt even have to submit an invoice; the managed care companies will pay whatever the invoice says, as long as she indicates that on the form.