Pediatric Coding Alert

Question: When we perform a difficult procedure such as catheterization, can we bill extra? What about using modifier -22?

California Subscriber  
Answer: When performing certain procedures, such as bladder catheterization, pediatricians may perform more work than internists treating adults. These procedures take extra time and effort when performed on a child, yet CPT doesn't recognize this with a single modifier. Pediatricians should consider modifier -22 (unusual procedural services). Modifier -22 will add to your practice's reimbursement for the code -- practices will have to determine the amount, however. Many pediatric practices double the fee.
 
An aggressive pediatric biller should consider appending modifier -22 to certain codes (examples below) if the documentation supports it. Most payers' computer systems automatically kick out claims with modifier -22, so coders must file manually. Before reimbursement, the payer will want documentation of significant extra effort. Do not assume that a payer will give you more for a service just because of the age or weight of the patient. Avoid appending modifier -22 every time you bill these codes.

Catheterization
 
A relatively simple procedure in an adult, catheterization (53670*, catheterization, urethra; simple) may not be simple in a child. Extra time will be required and extra skill as well. Appending modifier -22 to 53670* may increase the reimbursement, but your documentation must indicate that extra work was performed.
 
Code 53675* (catheterization, urethra; complicated [may include difficult removal of balloon catheter]) for a complicated catheterization has a higher relative value unit than 53670* but may not be as appropriate for the pediatric patient as 53670*-22.
 
Do not use 51010 (aspiration of bladder; with insertion of suprapubic catheter) for a bladder catheterization done to obtain a urine specimen in the office. This would not be done in the office by a pediatrician.
Suturing
 
Laceration repairs that you perform in the office (12001*, 12011*-12013) require extra time and skill in children. An adult would sit still; a 5-year-old might not, making treatment of facial lacerations in particular a time-consuming task. Appending modifier -22 would be appropriate given the proper documentation.
 
Some pediatricians perform more extensive lacerations, and they should bill using the appropriate laceration codes, also with modifier -22, if justified.
Lumbar Puncture
 
Append modifier -22 to a spinal tap (62270*, spinal puncture, lumbar, diagnostic) that is particularly difficult, such as one with multiple sticks. Document both time and difficulty in the record.
Removal of a Foreign Body
 
Foreign-body removal, whether from the nose (30300*, removal foreign body, intranasal; office type procedure), ear (69200, removal foreign body from external auditory canal; without general anesthesia) or skin (10120*, incision and removal of foreign body, subcutaneous tissues; simple), might be so difficult and time-consuming that modifier -22 is justified. For example, it may take extra skill to remove a [...]