Pediatric Coding Alert

Answer: The claim is partially correct. You should code 99212-25 as well as 11750 and 11750-50 but not 17250.

E/M: Because the diagnosis is new to one toe you could justify 99212 (Office or other outpatient visit for the evaluation and management of an established patient ...). The patient presents for follow-up of one ingrown toenail. The pediatrician however has not previously examined the other now ingrown toenail.

You should also append modifier -25 (Significant separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to 99212. The modifier indicates the pediatrician performs a significant separate service from the ingrown toenail removal.

Be prepared to fight with the managed-care organization (MCO) for E/M payment. Send a copy of the records indicating that the previous visit didn't involve the other toe nail.

Excision: You should code each toenail removal. Report 11750 for the first complete removal and 11750 for the second removal.

You correctly append modifier -50 (Bilateral procedure) to the second 11750 (Excision of nail and nail matrix partial or complete [e.g. ingrown or deformed nail] for permanent removal). The modifier tells the insurer that the pediatrician performs the toe removal as a bilateral procedure.

Cauterization: You shouldn't use 17250 (Chemical cauterization of granulation tissue [proud flesh sinus or fistula]). The excision codes that you are reporting preempt the cauterization code.