Pediatric Coding Alert

Scenario: A child who had ear tubes placed by an otolaryngologist (ENT)69436 (tympanostomy [requiring insertion of ventilating tube], general anesthesia), the most common code used for small childrenis brought into the pediatricians office (not to the ENT surgeon) because the child has been pulling at his ears. The mother was concerned, but not sure the problem was related to the tubes, so she didnt go back to the surgeon. The pediatrician must then bill for this visit.

Some carriers may deny this claim because of the global period of the surgery. However, Richard H. Tuck, MD, FAAP, a founding member of the RBRVS RUC of the American Medical Association says, For any surgery, if a pediatrician sees the child afterward, the pediatrician should get paid.

Similar situations occur when a tonsillectomy or a circumcision are done by specialists, and the child comes in for a preventive-medicine visit during the global period. Clearly, the pediatrician should be paid for that well visitit had nothing to do with the surgery. The insurer should not consider a physician who did not do the surgical procedure as being restricted by that global, says Tuck, who practices with PrimeCare Pediatrics of Zanesville, OH, and is a regional coding resource for the American Academy of Pediatrics (AAP). In the case of the tubes, says Tuck, the ear-pulling may have nothing to do with the ears at all. Frequently the problem is something thats unrelated, such as a sore throat, he explains. If indeed the problem is related to the tubes, then the pediatrician might send the child back to the ENT surgeonwho would not be able to bill for his service if the date he sees the patient is still within the global period for the surgery.

Another view comes from Bernadette Robinette, office manager for Pediatric Care Incorporated, a solo practice in Hendersonville, TN. If a mom calls a couple of days after the tube surgery saying the child is pulling at his ears, I would say its a good idea to go back to the ENT, says Robinette, who has been a medical office manager for 23 years. Obviously, if its not related to the surgery, its not for the ENT. It depends on the symptoms. But why should the pediatrician step in at this point if the responsibility is the specialists? But ultimately, Robinette agrees with Tuck: If the pediatrician does see the patient, even if it is during the global period, the pediatrician should bill forand be paid forthat visit. The exam should be coded as an office visit (99211-99215), with the level depending on the documentation of services provided.

It is clear from the modifiers listed in CPT that restrictions on payment during the postoperative period are not meant to apply to different physicians. Modifier -79 is for an unrelated procedure or service by the same physician during the postoperative period. Note that same physician is clearly stipulated. If a different physician is caring for the patient, no modifier is needed.

Also, modifier -24 (unrelated evaluation and management service by the same physician during a postoperative period) is the modifier some insurance plans expect hereand then they will pay, says Thomas Kent, CMM, former office manager for a pediatric practice and principal of Kent Medical Management in Dunkirk, MD. Some office managers say its easier to append a -24 modifier and send the claim back for reconsiderationeven though the physician is different.

While its true that modifier -24 is for service by the same physician, the use of the modifier in this situation seems to make it easier for insurance companies to understand what has occurred. There is no specific modifier for this situation, and theoretically, since the physician is different, no modifier should be necessary. We have included modifier information here, however, because sometimes these modifiers can help.

Also, different diagnoses may help, Kent says. For example, this problem most often occurs when the same diagnosis as the surgery is used for the office visit. If the child does have otitis media, then you must use otitis media as the diagnosis for the office visit, says Kent. However, sometimes the otitis media diagnosis is applied incorrectly, either because the computer already has this listed as the default diagnosis, or because the coder mistakenly believes the prior surgery diagnosis must also be listed.