Pediatric Coding Alert

Tally your score with the following three solutions.

Determine whether you're ready for summer coding cases by checking your answers to our summer coding quiz on page 34 against these three solutions. You may also want to share this summer coding advice with your office staff to ensure that everyone is on the same page when it comes to coding these scenarios.

Get Ready to Treat Sunburns

Answer 1: You'll need to answer the "local treatment" question before you can nail down the correct sunburn treatment code. Red skin -- even an area that might technically be "burned" -- doesn't automatically lead to reporting a burn treatment code. If your staff doesn't administer treatment specifically for the sunburn, you may only report an E/M code (99201-99215) for the check.

Example: A mother brings her son to your office because of his sunburned shoulders and back. After examination, the pediatrician determines the burn is superficial and will heal on its own in a few days. He instructs the mother to have her son wear his shirt while outdoors. You'll report the appropriate E/M code such as 99212 for an established patient or 99201 (Office or other outpatient visit for the evaluation and management of a new patient ...) for a new patient.

If, however, the child in the example above has a more severe burn, his care might qualify for code 16000 (Initial treatment, first degree burn, when no more than local treatment is required). Check whether you treat the burn with topical medication (anesthetic) or other options. This code has a zero day global period, and has an RVU of 1.98, which translates into about $67.27 in payment.

Example: If the physician diagnoses a first-degree burn and treats it as such--for example, with a compress on the area--you can typically report the E/M code as well as 16000. 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 the E/M code in this situation.

Nail Down Substitute Physician Coding

Answer 2: The general rule, particularly for payers that follow Medicare payment guidelines, is to use modifier Q6 (Service furnished by a locum tenens physician) when billing for substitutes. Locum tenens reporting guidelines govern all services provided to Medicare patients by a substitute physician. The modifier simply tells the payer that a locum tenens physician provided the services -- a one-way exchange between physicians. Medicare payment rules typically apply to Medicaid, and have been adopted by many private payers.

Rule of thumb: You must append modifier Q6 to every procedure code on a claim for a substitute physician. But remember, you should still send the bill out under the regular physician's name. For instance, when a substitute physician provides a level-two E/M for an established patient, you would bill 99212-Q6 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem-focused history; a problem-focused examination; straightforward medical decision-making) under the primary physician's National Provider Identifier (NPI).

Remember 'E' Code for Bee Sting Diagnosis

Answer 3: You read correctly. If the documentation supports it, you can report an E/M code along with an antigen injection code -- but don't forget your ICD-9 codes to demonstrate medical necessity.

For the injection, report 95130 (Professional services for allergen immunotherapy in prescribing physician's office or institution, including provision of allergenic extract; single stinging insect venom). Don't forget to link these ICD-9 codes to 95130 to demonstrate medical necessity for the encounter:

For the E/M service, report the appropriate code from the 99201-99215 series. As with 95130, you should attach ICD-9 codes 989.5, 995.0 and E905.3 to the E/M service to prove medical necessity for the evaluation and management service.

Don't forget: Attach modifier 25 to your E/M code to show that the E/M and the injection were separate services.