Pediatric Coding Alert

Question: A patient required an in/out cath for residual urine. Can I report an office visit in addition to the cath? Do I need a modifier?

Michigan Subscriber

Answer: First, check that the pediatrician performed and documented a medically necessary E/M service related to the cause of the residual urine requiring catheterization. If so, you can report an office visit (99201-99215, Office or Other Outpatient Services) with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) in addition to the catheterization (51701, Insertion of non-indwelling bladder catheter [e.g., straight catheterization for residual urine]).

Key: The physician should have written/dictated a separate procedure note. Alternatively, if a nurse performed the catheterization, she should have written an incident-to procedure note that the pediatrician countersigned. Notes that show the office visit's history, examination, and medical decision making separate from the procedure description of the catheterization will help show that both the E/M and the procedure deserve payment. To indicate that the office visit is significant and separately identifiable from the procedure, append modifier 25 to 99201-99215.