Pediatric Coding Alert

Question: Based on a mother's complaint that her son who has tubes is pulling on his ears, my pediatrician checks the child's tubes. How should I code the pediatrician's tube check? The tubes are intact.

New York Subscriber

Answer: You should submit the appropriate-level E/M service (99201-99215, Office or other outpatient visit for the evaluation and management of a new or established patient ...), depending on the history, examination and medical decision-making that the pediatrician performs.

CPT doesn't contain a specific code for postsurgical tube checks. The surgical procedure's global period includes the postoperative care when the surgeon who placed the tubes, such as an otolaryngologist, checks them. But when a different physician evaluates the tubes or if the child has a complication, you should include the tube check in the office visit's examination.

If the child doesn't have an ear infection, link the office visit with otalgia (such as 388.70, Otalgia, unspecified). When the pediatrician diagnoses otitis media, assign the appropriate ICD-9 code (for instance 382.00, Acute suppurative otitis media without spontaneous rupture of ear drum).