Pediatric Coding Alert

Question: After examining a patient in the office and finding fecal impaction causing urinary retention, our pediatrician treated the patient as an outpatient in the hospital with catheterization, an enema, and observation. How should we code for the office visit and the coordination of care at the hospital?

New Jersey Subscriber

Answer: No CPT code exists for a rectal examination or for disimpaction. You should use an E/M office code (99201-99205 for a new patient, 99211-99215 for an established patient). Incorporate the office work and the hospital work in the same code. Use prolonged services to capture the doctor's extra time spent with the patient. If the level of service was a 99214, you should report prolonged services if the time exceeded an additional 30 minutes of the 25 minutes CPT allots for that level. If you spent a total of an hour and a half or more, use the prolonged services codes (+99354 for the first hour, +99355 for each additional 30 minutes).

The new fecal impaction code (99511, Home visit for fecal impaction management and enema administration) for 2002 must be used for visits at home.

You should use 45915* (Removal of fecal impaction or foreign body [separate procedure] under anesthesia) only if anesthesia is provided, which did not occur.

For the catheterization, bill 53670* (Catheterization, urethra; simple). The E/M services code includes the enema administration.

Answers for Reader Questions and You Be the Coder contributed by Richard A. Molteni, MD, FAAP, member, CPT editorial panel, chairman, American Academy of Pediatrics' (AAP) perinatal section, vice president and medical director, Children's Hospital and Regional Medical Center, Seattle; Richard H. Tuck, MD, FAAP, founding chairman, AAP coding and reimbursement committee, practicing pediatrician, Zanesville, Ohio; and Thomas A. Kent, CPC, CMM, president, Kent Medical Management, Dunkirk, Md.