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Pediatric Coding Alert

Summer Coding:

Take the Pain Out of Coding Sunburns, Bee Stings, and Other Summer Visits With These Quick Tips

Published on Tue Jul 31, 2012

Know how swimmers' ear code will change under ICD-10.

Summer weather means swimming, camp, and lots of time outside -- which can result in additional challenges for your pediatric practice. Check out this quick summer coding primer for answers to your most pressing seasonal coding issues.

1. Know Swimmers' Ear Code for 2012--And Beyond

If you see a patient with swimmers' ear, it might be tempting to report a code from the 380.10 series (Infective otitis externa, unspecified) " but that would be a mistake. ICD-9 includes a specific code for acute swimmer's ear (380.12), which you should report anytime the pediatrician identifies the condition in the patient's chart.

ICD-10 update: Once you are required to use the ICD-10 codeset (which will happen in October 2014 if CMS finalizes its current proposal), you'll instead choose from one of three codes, rather than using the single 380.12 code. The applicable ICD-10 codes will be as follows:

  • H60.331 -- Swimmer's ear, right ear
  • H60.332 -- Swimmer's ear, left ear
  • H60.333 -- Swimmer's ear, bilateral
  • H60.339 -- Swimmer's ear, unspecified ear

2. Be Careful Identifying Sunburns As 'First Degree'

Concerned parents often bring in sunburned patients for evaluation, and most -- but not all -- sunburn cases merit E/M codes.

Example: An established 12-year-old patient visits the office because his father is concerned about his sunburned back. The physician examines the patient's back and decides the burn is superficial and will heal on its own in a few days. The physician advises the patient to avoid lying on his back and to wear his shirt while in the sun. She recommends using a topical aloe gel to help relieve pain.

Code it: The physician didn't spend a lengthy amount of time examining or counseling the patient, and didn't administer any treatment. Therefore, the visit leads to a low-level E/M code such as 99212 (Office or other outpatient visit for the evaluation and management of an established patient ...).

Switch to 16000 for More Extensive Care: If, however, the physician provides local treatment to the patient's sunburn, choose 16000 (Initial treatment, first degree burn, when no more than local treatment is required) for the encounter.

Watch for: A first-degree burn usually only reddens the skin. The patient might have some swelling and mild blistering, but this is normal and usually resolves quickly. Treatment of a burn categorized by 16000 would probably include use of topical medication, such as a topical anesthetic. The physician might also apply bandages to the burned area, but first-degree burns rarely require more than an application of moisturizer to soothe the skin.

In some situations, the physician might provide both an E/M service and local treatment of the patient's burn during the same encounter.

Example: An established six-year-old patient visits your office with a light bulb burn on her right hand. The injury is red, swollen, and non-blistering. The patient says the redness worsened overnight. The pediatrician performs a problem-focused exam and finds that the palm is erythemous, swollen, and hot. He applies sterile gauze over the burn and surrounding non-burned tissue, using tape to secure the bandage. He advises the patient to continue covering the burn with gauze, but to keep the tape off any burned areas. He also tells the patient to keep the burn away from oils, ice, and cold water. The physician's exam qualifies as moderate medical decision-making.

In this instance, you can report both an E/M and a burn treatment code. On the claim, report 99212 for the E/M with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to show that the E/M and treatment were separate services. Also include 16000 for the treatment.

3. Bee Stings: Differentiate Between Anaphylaxis and Allergy

Scenario: A nine-year-old patient develops generalized hives after a bee sting. She suddenly starts wheezing, so her mother brings her to your practice for treatment.

Identify the Reaction Reason: Your first thought might be to assign an allergic reaction diagnosis for the patient -- but that's not your best choice in this case. Although allergic reactions are a type of anaphylaxis, grouping them together when it's time to code will not only result in the wrong ICD-9 code, but will also undermine the severity of the encounter from the payer's perspective.

Difference: Allergic responses involve local or general reaction to one body system, such as the skin. Anaphylactic shock, by contrast, affects multiple body systems. Anaphylaxis syndrome is an explosive multisystem immune reaction. Generally, skin and respiratory symptoms appear first, but cardiac and gastrointestinal problems may also develop.

For instance: A bee sting patient presents with initial symptoms of allergic reaction (995.3, Allergy, unspecified), hives (708.0, Allergic urticaria), and wheezing (786.07). Because the symptoms involved multiple body systems (skin and respiratory), you'll report a more specific anaphylaxis diagnosis, such as 995.0 (Certain adverse effects not elsewhere classified; other anaphylactic shock), instead of individual symptoms.

Additional: Before submitting the claim with 995.0 as the only diagnosis, consider the primary reason for the encounter -- the bee sting. In the case of anaphylaxis due to insect bites, the venom triggers the reaction. Therefore, list 989.5 (Toxic effect of other substances, chiefly nonmedicinal as to source; venom) as the primary diagnosis and 995.0 as secondary. Reporting 995.0 without 989.5 would omit the reason for the shock.

Finally, add E905.3 (Venomous animals and plants as the cause of poisoning and toxic reactions; hornets, wasps and bees) to identify the source of anaphylactic syndrome. Some payers might not accept external cause codes, but including E905.3 gives a more complete picture of the situation.

4. Consider Location for FBRs

Your patients probably love to run around with bare feet during the summer months--but the absence of shoes means an increase in splinters, glass, or other foreign objects in patients' feet. Keep in mind that you must assign the correct foreign body removal (FBR) code based on location.

For example: Using a needle to make an incision, a pediatrician removes a wood splinter from a patient's right foot.

Code it: Before sending in a claim for the FBR, make sure you have assigned the most specific code for the anatomical area treated. For a foot FBR, CPT contains a specific code (28190, Removal of foreign body, foot; subcutaneous).

If the pediatrician had instead removed a splinter from the patient's hand, you would use the general FBR code 10120 (Incision and removal of foreign body, subcutaneous tissues; simple).

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