Pediatric Coding Alert

Question: A payer just denied a claim for a chemical cauterization of an umbilical granuloma in a newborn. We billed for an office visit using 992XX with modifier 25, 17250 for the procedure, and P83.81 for the diagnosis. What are we doing wrong?

Texas Subscriber

Answer: It’s hard to say what’s going on with this claim, as the combination of 992XX (Office or other outpatient visit for the evaluation and management of an/established patient …) with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) and 17250 (Chemical cauterization of granulation tissue (ie, proud flesh)) shows no bundling issues or National Correct Coding Institute (CCI) edits.

You might, however, want to check with your payer regarding the diagnosis code you are using. While P83.81 (Umbilical granuloma) should be correct, some payers want two different diagnosis codes, one for the visit and one for the procedure. In this case, you could try using P02.60 (Newborn affected by unspecified conditions of umbilical cord) as the diagnosis for the procedure, keeping P83.81 for the visit.