Pediatric Coding Alert

Rule: Scheduled wart removal, I&D = procedure only

You need a new system to determine whether you should code an E/M in addition to a minor procedure.

Say 'Goodbye' to Stars

"Several years ago it was acceptable to use a 99213 (or other appropriate-level E/M code) as well as codes like 17000, 17003, 30300, 10120, 10060, 11200, etc.," says Dru Heffington, business manager at Cool Springs Internal Medicine and Pediatrics Clinic in Brentwood, Tenn. But that's when a little symbol gave you a clue as to what some minor procedures included.

Starred procedures, designated with an asterisk (*), indicated codes that represented the surgical procedure only. The CPT convention meant that the code did not include any related pre- and postoperative services.

But starred procedures are no longer present in CPT, says Peter Rappo, MD, FAAP, a practicing pediatrician and clinical professor of pediatrics at Harvard Medicine School in Boston. In 2004, the AMA ended this system.

A star, however, was never an automatic green light for also reporting an E/M. Instead, the service still had to qualify as significant and separately identifiable from the procedure (meet the criteria for modifier 25, Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service). That key requirement remains the underlying factor.

Identify a Standalone E/M Note

Check if documentation supports a separate E/M service by excluding procedural items. Minor procedures contain some associated work, which CPT refers to as the code's surgical package. This "includes a preprocedure evaluation, the actual procedure and postprocedure care up to a set number of days," says Jeffrey F. Linzer Sr., MD, FAAP, FACEP, associate medical director for compliance and business affairs at EPG in Egleston, Ga.

Don't overlook: To also bill an E/M code, the service note must stand on its own. You have to have a history, examination and/or medical decision-making that supports the office visit level you are reporting. This cannot overlap with the procedure note. When you do have two separate notes--one for the service and one for the procedure--and the service note is codeable by itself, you should report the E/M service appended with modifier 25.

Want some solid examples of modifier 25 in action? Let's look at what a significant, separate service means in addition to some of the procedures Heffington listed above.

Code 25-Service When a Spot Is Evaluated

Expect to code for a service in addition to wart removal when you first have to diagnose the problem. Compare these two examples:

Example 1: At a preventive medicine service, a mother doesn't have time for you to remove a wart from her child's hand, so she schedules an appointment for the next week. During the second visit, you only remove the wart. "Code the wart removal only," says Donelle Holle, RN, a pediatric nurse with more than 28 years of coding and billing experience for pediatric services. You already knew the problem, so no preprocedure evaluation was necessary.

Example 2: Alternatively, a mom presents with a child for discomfort and a spot on the child's hand. "I don't know what it is," the mother tells the nurse. You come in and ask questions about the lesion, such as when the mom first notice it, if she noticed any changes to it since then, etc. You evaluate the lesion and diagnose a wart. You offer treatment options, explain what removal techniques would entail, and discuss associated risks and expectations including possible reappearance.

You document two separate notes: one for the E/M service and one for the procedure. In this case, code the wart removal (17110, Destruction [e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement], of benign lesions other than skin tags or cutaneous vascular lesions; up to 14 lesions) and the office visit (99201-99215, Office or other outpatient visit) appended with modifier 25, Holle says.

Problem: Although CPT does not require different diagnoses to report a modifier 25 E/M service, insurers often don't pay for an office visit with wart removal using the same diagnosis. Linking different diagnoses to the E/M, such as pain of the hand (729.5), and the wart treatment (078.10, Wart) will help the payer see the separate and distinct services you provided.  

If the payer still won't cover the separate office visit, bill it anyway when documentation supports it. You can then show insurers down the line the value and amount of your services.

Watch out: CPT 2007 revised 17000 (Destruction [e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement], premalignant lesions [e.g., actinic keratoses]; first lesion) and +17003 (... second through 14th lesions, each [list separately in addition to code for first lesion]) for destruction of malignant lesions. Codes 17110 and 17111 (... 15 or more lesions) are the new wart removal codes, Holle says. CPT 2007 revised the destruction codes so that "17110 reflects up to 14 removals, not per removal as 17000 did."
 
Code E/M for Abscess Exam
 
Apply the "scheduled for procedure usually means no associated E/M" rationale to incision and drainage (I&D) cases, such as 10060 (Incision and drainage of abscess [e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia]; simple or single).
 
"If this is the first time the physician saw the patient for the abscess and decides to do I&D based on this initial exam, you should code the office visit in addition to the I&D," says Christine Dudek, RHIT, with Medical Associates Clinic and Health Plans in Dubuque, Iowa. "I would code only the I&D if the physician tells the patient to come back in 7-10 days for a recheck and repeat I&D."

Key: The visit must be separately identifiable from the I&D, including documentation of a history, exam and the decision-making process that led to the procedure. Attach modifier 25 to indicate this. Before performing an unscheduled procedure, the pediatrician "has to identify the need for the procedure," Dudek says.

Again, separate documentation of the E/M service and the procedure will help in an appeal. And, whenever possible, use distinct supporting diagnoses for each service. For example, for leg pain and an abscess, you could use leg pain (729.5) for the E/M, and leg abscess (682.6) for the I&D.