Pediatric Coding Alert

The next time a patient requires hydration therapy, therapeutic injection, catheterization or a chest x-ray following an E/M service, your procedure pay may depend on modifier 25, thanks to a new batch of edits.

The latest version of the Correct Coding Initiative (CCI), effective April 1, extends the intravenous infusion (90760, 90765) and therapeutic, prophylactic or diagnostic injection (90772-90774) E/M bundles to the facility setting.

CCI version 14.1 includes intravenous infusion (90760, 90765) and therapeutic, prophylactic or diagnostic injections (90772-90774) in all facility and home E/M services (99217-99350). CCI 12.0 had made 90760, 90765 and 90772-90774 components of office-based E/M services.

CMS bases the injection-inpatient/observation edits on "standards of medical/surgical practice" and allows a modifier breaker. The edit simply codifies a CPT guideline. The Hydration, Therapeutic, Prophylactic, and Diagnostic Injections and Infusions (Excludes Chemotherapy) introductory notes state, "If a significant, separately identifiable Evaluation and Management service is performed, the appropriate E/M service code should be reported using modifier 25 in addition to 90760-90779," says Denae M. Merrill, CPC-E/M, owner of Merrill Medical Management in Saginaw, Mich.

Relief: The new edit doesn't change much, Merrill says. "These services have been bundled together since the creation of 90772 (Therapeutic, prophylactic or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular)."

In fact, the bundles bring CCI in line with CPT. Version 7.3 of CCI said that all codes with "XXX" global periods, such as 90772, include a minor related E/M service, says Barbara J. Cobuzzi, MBA, CPC-OTO, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions in Tinton Falls, N.J. Therefore, practices couldn't bill those codes with an E/M service unless they could justify using modifier 25. But each individual carrier was able to decide whether to implement that rule.

"Now that the CCI is bundling some of those codes (such as 90760, Intravenous infusion, hydration; initial, 31 minutes to 1 hour) with E/M services, they're not leaving it to the carriers anymore," Cobuzzi says.

CCI 14.1 similarly includes catheterizations (51701-51702, 0 global days) and chest x-rays (71010-71020, XXX global days) in many of the same facility E/M services. Under "CPT Manual and CMS coding manual instructions," CCI creates these bundles:

You know you can't just willy-nilly append modifier 25 to the E/M service. The pediatrician must perform and document an E/M service that is significant and separately identifiable from the minor evaluation included in the hydration therapy or therapeutic injection.

Key: To avoid overlooking opportunities to correctly capture a service in addition to the minor procedure, you have to spot E/Ms that qualify as significant and separate. Merrill suggests zooming in on these defining marks:

- Separate:

1. As a result of the evaluation, the provider decides to do a therapeutic or diagnostic intervention

2. At an encounter for a planned procedure, the provider and/or patient identifies a completely separate problem that is significant enough to require workup of the key components (history, exam and medical decision-making).

Significant:

Evaluation of the problem and decision on how to treat it is:

1. over and above routine for that E/M service

2. above and beyond the usual preoperative and postoperative care.

How it works: A pediatrician evaluates a 2-year-old child presenting with vomiting and diarrhea. The child's lips are dry, and his skin is shrunken. The physician performs and documents a level-four office visit, in which he diagnoses gastroenteritis with a complication of dehydration. He orders hydration therapy, which lasts 45 minutes.

The scenario meets the significant, separate criteria that modifier 25 requires as described under "separate" definition 1: "As a result of the evaluation, the provider decides to do a therapeutic or diagnostic intervention." Therefore, you may report the office visit (99214, Office or other outpatient visit for the evaluation and management of an established patient ...) appended with modifier 25 in addition to the hydration therapy (90760).

Tip: Although CPT does not require separate diagnoses to report a modifier 25 service, linking 99214 and 90760 to the respective ICD-9 codes will help distinguish the E/M from the therapy. To do so, follow these steps:

• In box 21, enter 009.1 (Gastroenteritis presumed infectious) as diagnosis 1 and 276.51 (Dehydration) for diagnosis 2.

• Complete box 24D and E as follows: