Pediatric Coding Alert

Editors Note: Coding advice and strategies offered in this section are verified by various members of PCAs Editorial Advisory Board.

Billing for Laceration Repairs
with Dermabond

For the procedure, you should use the laceration repair codes. You would probably only use the starred procedure codes (those that include the surgical procedure only), as Dermabond would be used on the smaller lacerations (12001, 12002, 12004, 12011, 12013, 12031, 12032, 12041, and 12051). There is a proposal at the AMA to include verbiage about Dermabond in the laceration repair codes, so there will be no question that they are appropriate when this product is used instead of sutures. But the real problem is getting paid for the substance itself. There is no CPT code for Dermabond repair. And there is no HCPCS code for the supply. So you need to use CPT 99070 and attach a copy of the invoice. 99070 is for supplies and materials provided by the physician over and above those usually included with the office visit or other services rendered. It is under special services and reports and often unpaid. As one practice told us, Were not using Dermabond. It costs too much, and we have no way of getting reimbursed. Some experts think it is unlikely that there will ever be a HCPCS supply code for Dermabond, since there isnt one for sutures (sutures are included in the laceration repair codes).

Tips on Camp Physicals

A 15-year-old comes in for a complete physical prior to entering an Outward Bound program for teens with behavioral problems. The last physical took place less than 12 months ago. Insurance coverage doesnt pay for more than one well visit a year. Yet the parent insists that insurance will pay if only the practice bills correctly. How do you respond?

Collect from the patient up frontimmediately after the child has been examined, advise our sources. If the parent resists, call the insurance company immediately, with the parent standing by. You can call the number on the back of the parents insurance carddont bother your provider relations person with this. When the parent hears from the insurance company that the visit isnt covered, he or she will understand who is responsible for the charge.

Note: If you want to make sure you collect for these camp physicals, you should get the payment before, not after, the exam.

New Vaccine Administration Codes

Now that there are finally codes for administering vaccines (90471 for a single or combination vaccine, 90472 for two or more single or combination vaccinessee article on the cover of the November issue of PCA), here are the rules on how they should be used, according to Bela Agrawal, senior health policy analyst at the American Academy of Pediatrics.

If immunizing as part of a preventive-medicine visit, you should use the appropriate well-visit code (99381-99385, 99391-99395) as well as the vaccine product code and the administration code. If, however, the child has an ear infection, for example, and the pediatrician decides not to give the immunizations until it has cleared up, then, when the child comes in for the immunizations, you would not use 99211 (office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician). Instead, you should only report the administration code and the vaccine product code, says Agrawal.

Billing Separately for Conscious Sedation and Procedures

Can the conscious sedation codes (99141 for intravenous, intramuscular or inhalation, 99142 for oral, rectal and/or intranasal) be used in addition to procedures, such as laceration repair or endoscopies? It depends. If the anesthesia is already included in the codes value, then you cant bill separately, says Joel Bradley, Jr., MD, FAAP, a regional coding trainer for the AAP who practices in Clarksville, TN. If its a procedure that may or may not be done using sedation, such as putting sutures in a facial laceration, then yes, you can bill separately, Bradley says. But with endoscopies, sedation is included in the work component of the RVU, he adds. Most of the time there would be some sedation for adults for endoscopies, for example. But not for suturing. So if a procedure is normally done with sedation, do not use the conscious sedation codes, says Bradley. If it isnt, then do use them.

Tip: There are some simple endoscopic procedures which would require only topical anesthetics when performed on adults, but which, because of the need for the patient to stay still, may require conscious sedation in children. In these cases it is correct to bill conscious sedation codes in addition to the procedure, even though general anesthesia is not normally used with the procedure in adults.

Finally, if you bill conscious sedation, you must have a trained staffer, such as a nurse, present to monitor the patient. You cannot use conscious sedation codes if a second physician is providing the sedation and monitoring the patient.

Cleaning Pus from the External Auditory Canal

Shlomo Friedman, MD, who practices in Richardson and Dallas, TX, writes to ask how to code for removing the pus from the external auditory canal in cases of purulent otitis media. I remove the pus by inserting a cotton-tipped probe repeatedly until I can see the drum or the ventilation tube and the drum, he writes. This procedure is time-consuming and requires knowledge. What is the CPT code, and does the CPT code change when two ears are done?

There is a code for cerumen removal (69210), but there isnt any code for cleaning pus from the ear. The best solution is to bill a higher level office visit, possibly based on time.

Another possibility, although it probably wont get paid, is to use 69399, which is for an unlisted procedure, external ear. But the pediatrician would have to develop his own charge for that, by extrapolating what he charges for an office visit, and looking at the amount of time he spends on the procedure.

As for charging twice for two ears, thats tricky. The cerumen removal code is specifically for one or both ears. That means CPT doesnt pay twice. Some practices do charge twice for two ears, at least on their fee schedules.