Pediatric Coding Alert

This months column is by Richard H. Tuck, MD, FAAP, a member of the American Academy of Pediatrics (AAP) committee on coding and reimbursement and consulting editor of this newsletter. Tuck practices with Primecare Pediatrics in Zanesville, Ohio.

When it comes to reimbursement, its a surgeons world. This is a product of traditional indemnity insurance plans, which allowed for inflated fees for procedures. But pediatricians who use only the evaluation and management (E/M) services codes are cheating themselves.

My plea is that pediatricians capitalize on procedures that they do, and stretch themselves to do procedures they might be uncomfortable doing because they are used to referring to specialists. For many of these procedures, pediatricians dont need to referthey can do these procedures themselves. Here are my recommendations for procedures that pediatricians should perform:

1. Circumcisions. Many pediatricians dont do circumcisions. I strongly feel we should because we do the education and the follow-up. Circumcision code 54150 (circumcision, using clamp or other device; newborn), has a fee range from $127 to $164, while CPT 54160 (circumcision, surgical excision other than clamp, device or dorsal slit; newborn) has a fee range from $212 to $257.

Because pediatricians dont do the procedure until the infant is ready, they are able to provide better care than other providers might offer. Performing the circumcision in the hospital instead of the office also has the benefit of the hospital absorbing the cost of the practice expense: the nurse, the circ tray, antibiotic ointment, etc.

2. Wart removal. Code 17110* (destruction by any method of flat warts, molluscum contagiosum, or milia; up to 14 lesions) fee ranges from $71 to $87. Some pediatricians dont do this because they are afraid of using the liquid nitrogen. Even in our office, four of us use it, but one isnt comfortable with it. If you dont have liquid nitrogen or another method of treating warts, you are losing money unnecessarily every time you refer these children to dermatologists.

This is a starred procedure, which means you can charge an office visit at the same time. But you have to use a modifier -25 (significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) on the office visit in order to get paid under CPT 2000 rules.

3. Chemocauterization of umbilicus. Code 17250* (chemical cauterization of granulation tissue [proud flesh, sinus, or fistula]) fee ranges $67 to $81. Sometimes the pediatrician needs to destroy excessive healing tissue known as proud flesh. Silver nitrate is used.

If you neglect to bill for this procedure, you are denying your practice deserved reimbursement. This is a starred procedure, so you can charge an office visit as well. Make sure you put modifier -25 on the E/M service.

4. Cauterization of nosebleed. Code 30901* (control nasal hemorrhage, anterior, simple [limited cautery and/or packing] any method) fee ranges from $138 to $175. This is another procedure which pediatricians perform often, yet they only charge an office visit. This is a starred procedure so you can charge an office visit and the procedure.

5. Suturing and Dermabond. Code 12011* (simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less), fee ranges from $151 to $181; 12001* (simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.5 cm or less) fee ranges from $115 to $140.

These should be mainstays of a pediatric practice. But pediatricians find that, for scheduling reasons alone, they send these patients to the ERespecially for suturing. If suturing requires local anesthesia, providing this without having an upset child is difficult. We have suturing done in the ER, because it is so disruptive to the schedule. However, I would support pediatricians doing the suturing themselves. Dermabond is another storyits easy to use and separately reimbursable. If you dont have Dermabond, get it and bill for this procedure. If you normally send children to the ER for suturing, try doing it with the liquid adhesive yourself.

Not only is it easier on the child, but you can get paid as well. Note that you use the same code whether the closure is by suture or Dermabond. This is a starred procedure, so you can bill an E/M service in addition to the procedure code. Use modifier -25 on the E/M service.

Note: Wound closure using adhesive strips alone is reimbursable only using the E/M services codes.

6. Burn dressing and debridement. Code 16020* (dressings and/or debridement, initial or subsequent; without anesthesia, office or hospital, small) fee ranges from $62 to $74. This takes a relatively small amount of effort, and is reimbursed relatively highly. Sending a child to the ER for this doesnt make any sense. The child may have to wait a long time while other more serious cases are seen first. You could handle it more easily in your office.

7. Would dressing and debridement. Code 11040 (debridement; skin, partial thickness) fee ranges from $68 to $83. This would be used, for example, when a child has been riding a bike, slides in the cinders and needs the wound to be cleaned, foreign bodies removed, and have the wound dressed. Traditionally, pediatricians think of this as an office visit.

And if you bill E/M code 99214, the fee range is slightly higher$80 to $97. But if you bill a 99213, the fee range is lower$53 to $67. This is an important code to remember, because usually with these visits you are also evaluating other aspects of the injury, such as a strain or a sprain. So in addition to the 11040, you will be billing an office visit as well, even though this is not a starred procedure.

8. Incision and drainage. Code 10060* (incision and drainage of abscess [e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia]; simple or single) fee range $91 to $108. This is a starred procedure, meaning you can charge for the office visit as well (with modifier -25).

9. Urinalysis. Code 81000 (urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, with microscopy) fee range $15 to $21; 81002 (non-automated, without microscopy) fee range $12 to $16. Pediatricians do not usually bill for this because managed-care organizations are not likely to pay for it. But its worth fighting for reimbursement for a procedure done so often. It may seem like a low fee, but it adds up.

10. Foreign body removal. Code 69200 (removal foreign body from external auditory canal; without general anesthesia), fee range $98 to $118; 30300* (removal foreign body, intranasal; office type procedure) fee ranges from $101 to $119. These are both procedures that pediatricians perform often, given the penchant of children to put things in their ears and noses. These procedures require good lighting and specialized equipmentin particular, alligator forceps and bayonet forceps. But often pediatricians do the procedures and forget to bill extra for them. Note that code 69200 is not a starred procedure, meaning you cant bill an office visit for it unless there is some other service you are providing, but code 30300* is a starred procedure.

Obviously, many of these procedures are emergencies. If it is an emergency that could be handled by the ER, this warrants the emergency code in addition to the procedure code. Use 99058 (office services provided on an emergency basis), fee range $70 to $100. If the insurance company objects, they need to be reminded that otherwise the child would have gone to the emergency room, which is much more expensive. There are patients we send to the ER -- children with significant lacerations, or who are in acute distress. We dont see critical cases in the office. But were fortunate enough to be in a group that allows us to see emergency patients. If one partner gets behind, someone can always take up the slack. We feel its important to furnish this service to the children we care for. Theres a benefit to being seen in a situation in which the parents and children feel comfortable.

Editors note: Fee ranges are from Healthcare Consultants of Americas 1999 Physicians Fee & Coding Guide.