Pediatric Coding Alert

Question: A patient came in because he had an abscess on his finger (no other problems). The pediatrician drained and treated the abscess and billed both 10060 and 99214, and the insurer paid for both. Is this correct? His documentation stated this: Physical assessment: Right second finger with small pustule with surrounding erythema to palmar aspect of area between PIP and DIP joints. Tender to touch, mom expressed pus from lesion yesterday. Assessment: Unspecified cellulitis and abscess of finger (681.00). Prescribe Omnicef 250 mg/5 mL oral liquid, ½ tsp. for 10 days. Lanced, tiny amount of pus/blood expressed, to lab for culture. Warm soaks as tolerated.

Answer: Unless there was a significant amount of time spent with this patient that isn’t shown in your documentation, this definitely would not qualify for 99214 along with 10060 (Incision and drainage of abscess [eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia]; simple or single). The evaluation and management service that the pediatrician performed appears to be lower level than what your physician billed. For instance, you could potentially report 99212-25 along with 10060 for this visit.

You should contact the insurer with a corrected claim and let them know of the overpayment that you received.