Pediatric Coding Alert

Question: We do some minor procedures here in our office, such as 16000 (initial treatment, first degree burn, when no more than local treatment is required), 11750 (excision of nail and nail matrix, partial or complete, [e.g., ingrown or deformed nail] for permanent removal), 41010 (incision of lingual frenum [frenotomy]), 26720 (closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; without manipulation, each), and 25660 (closed treatment of radiocarpal or intercarpal dislocation, one or more bones, with manipulation). Should we charge an office visit with these visits? If we should charge an evaluation and management (E/M) visit should we use the -57 modifier (decision for surgery)? Also, we charge a 36415* (routine venipuncture or finger/heel/ear stick for collection of specimen[s]) at a routine well visit. Should we use a -25 modifier on the preventive-care visit?

Lisa Aimes
Oak Ridge Pediatric Clinic, Oak Ridge, Tenn.

Answer: Except for 36415*, all the procedures you mention are not starred procedures. A starred procedure indicates that the code only covers the procedure itself, and that anything additional is to be billed with a -25 modifier (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). Because these procedures that you listed are not starred, they are the complete billing for that time and should not have any additional codes attached.

If an E/M service is performed in addition to any of the procedures listed here, it is indeed correct to bill the office visit with a -25 modifier, as well as the procedure. It is the if that is important. Here are two questions to keep in mind.

(1) Does the documentation show the office visit as significant and separately identifiable? To justify billing, both procedures should be documented as a separate paragraph and preferably on a separate page.

(2) Is the E/M portion significant? A child in the office with the complaint of a bean in the nose is unlikely to require a significant level of history, exam or medical decision-making to determine the need for a procedure. By contrast, the child who tumbled down two flights of stairs likely will require a thorough exam and some medical decision-making to locate the fractured finger and determine if there are any other injuries.

The significance of the E/M service is easy to determine if you separate the E/M note from the procedure note.