Pediatric Coding Alert

Question: We were denied payment on 99214-25, B07.8, and 17110 for removal of a verruca plana on a patient’s hand. We resubmitted with modifiers 57 and 59 but were denied with those as well. What should we be doing?

Oregon Subscriber

Answer: Your choice of modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) in this situation is actually the correct one. You would only use modifier 57 (Decision for surgery) if the evaluation and management (E/M) service resulted in a major surgery (one that has a global period of 90 days). And you cannot use modifier 59 (Distinct procedural service) to unbundle a procedure from an E/M service. Modifier 59 is specifically used to separate procedures.

The issue, then, seems to be whether your payer will allow you to code the 99214 (Office or other outpatient visit for the evaluation and management of an established patient ...) with the 17110 (Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions) service using the B07.8 (Other viral warts) diagnosis. For that, you need to show that the E/M service is both significant and separate, which is what the 25 modifier is telling your payer. You may be able to do this documenting one or both of the following:

1. A separate diagnosis for the E/M visit. Though this is not required, a diagnosis different from the B07.8 would definitely justify coding the 99214.

2. No overlap between the E/M visit care and the pre- and postoperative care included in the 17110.

None of the clinical responsibilities included with 17110, including any prep work, anesthesia, or wound care, can be documented in the care associated with the 99214.

Finally, it is also possible that your payer denied the claim because it has a policy of not allowing an E/M with a procedure on the same date of service (DOS). You should check your payer’s guidelines to see if it has such a policy.