Pediatric Coding Alert

Question: Is it possible to bill a separate evaluation and management (E/M) service for a patient returning several times for umbilical cauterization?

Wisconsin Subscriber

Answer: There are no National Correct Coding Initiative (NCCI) edits prohibiting you from doing so. However, your physician’s documentation will have to support a significant, separately identifiable E/M service, in order to report a code from 99201-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …) along with 17250 (Chemical cauterization of granulation tissue (ie, proud flesh)).

In other words, if the E/M service your physician performed is only the minor E/M typically associated with the procedure, you cannot add 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) and separately bill for the E/M. However, if your pediatrician did actually evaluate the patient to determine the need for the cauterization, and your documentation can demonstrate that, then you can bill for both the E/M service and the procedure with modifier 25 appended to the E/M.