Pediatric Coding Alert

Question: I received a denial from Medicaid for 99214-25, 078.19, and 17110. The carrier denied the claim as well with modifiers 57 and 59. What am I doing wrong?

Online Coding Group

Answer: First, you should stop thinking of modifiers as a way to get payment. You should make sure the modifier helps paint a more accurate picture of the encounter's circumstances.

You should reserve modifier 57 (Decision for surgery) for a same day E/M that results in the decision to perform a major surgery ��" one that has a 90-day global period. Modifier 59 (Distinct procedural service) is the modifier of last resort. Use it only when no other modifier more appropriately describes the circumstances. In the case of a problem-oriented office visit (OV), in which the pediatrician also identifies, manages, and treats a wart, the correct modifier is 25 (Significant, separately identifiable evaluation and management service on the same day of a procedure or other service). This indicates documentation supports the office visit as a significant, separately identifiable E/M from the usual pre- and post-care associated with the wart removal (17110, Destruction [e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement], of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions).

Medicare could have denied the claim for several reasons. Check three details:

1. Did the OV have a separate diagnosis? Although CPT does not require this to report an E/M-25 and procedure, two diagnoses help show the carrier the office visit's separateness.

2. Are you double dipping on the E/M? You can only count the pre- and post-care associated with the wart removal in 17110. The office visit code selected must not include these elements. See if a level-four service (99214, Office or other outpatient visit for the evaluation and management of an established patient ) is truly documented.

3. Does the carrier allow a same-day E/M and procedure? For instance, Colorado Medicaid will not pay for any E/M with a procedure on the same date of service (DOS).

" Answers to You Be the Coder and Reader Questions provided/reviewed by Victoria S. Jackson, former administrator/CEO of Southern Orange County Pediatric Associates Inc., and practice management consultant with JCM Inc. in California; and Jeffrey F. Linzer Sr., MD, MICP, FAAP, FACEP, associate medical director of compliance and business affairs for the division of pediatric emergency medicine, Department of Pediatrics at Children's Healthcare of Atlanta at Egleston; and Richard Tuck, MD, FAAP, a pediatrician with PrimeCare of Southeastern Ohio in Zanesville.