Pediatric Coding Alert

Question: Our physician charges an E/M service with a starred procedure (e.g., foreign body removal). There is no differentiating diagnosis; however, starred procedures are for surgical procedures only. Do you have any suggestions?

Tennessee Subscriber

 
Answer: You can bill an E/M with a starred procedure, but you must have proper documentation of a separately identified E/M service. For example, if you schedule a patient to come in to have a splinter removed, you would code only the foreign body removal, because this was a scheduled service. If the patient comes in because the finger is swollen and red, and the pediatrician examines it and finds a splinter, then you would code removal of foreign body (20520*, removal of foreign body in muscle or tendon sheath; simple) with the E/M services code (99212-99215) and modifier -25 (significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service). Modifier -25 states that a separate E/M was done on the same day, without a different diagnosis required. Further, starred procedures always allow the billing of an E/M service. Finally, if the patient comes in for a procedure and the doctor addresses a different problem, the same rule applies: Bill the procedure and the E/M with modifier -25.
 
Many modifier -25 visits could send up red flags with your payers. But if it is appropriate and documented correctly, bill it, and it will stand up in an audit.
 
A general diagnosis-coding rule is to use the sign-and-symptom diagnosis on the E/M code, and the definitive diagnosis on the procedure code.