Pediatric Coding Alert

Pediatricians are familiar with the coding dilemma of the child who presents for two services (such as a checkup and a sick visit) or a service and a procedure (such as a checkup and a wart removal) at the same encounter. Under certain circumstances, both can be billed by appending 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 service.

As recently as a year ago, coders hesitated to use modifier -25, resulting in unnecessarily restricted revenues. But more payers are recognizing modifier -25 and even accepting it electronically. So do not be afraid to use it, as long as it is justified by the performance of a separately identifiable procedure or service.

Although you can use modifier -25 only when a separate service is performed, this does not necessarily mean you need more than one diagnosis, according to CPT. But you must be able to document a separate service, which some coders recommend you provide by writing a separate paragraph, preferably on a separate page. Further, some payers ignore CPT rules and only pay on modifier -25 if there are two diagnoses, so when possible, use two diagnoses.

Some procedures are starred, meaning the code does not include any pre- or post-treatment work. It also means that for you to bill an E/M service with a starred code, CPT requires you to append modifier -25 to the E/M service. Modifier -25 is necessary even when a procedure is not starred, says Susan Callaway, CPC, CCS-P, an independent coding auditor and trainer based in North Augusta, S.C. "You need modifier -25 because your payer probably has its system set up to look first for a modifier, whenever they see an E/M and a procedure, to explain why both codes are there," Callaway says. "It has less to do with whether the procedure is starred or not, and more to do with what the payer views as a minor surgical procedure. Most insurance companies lean toward Medicare's definition of a minor procedure, and not CPT's starred procedure terminology," she says, adding that next year the stars will be eliminated from CPT Codes .

Preventive Medicine Service and Sick Visit

A common modifier -25 scenario in pediatrics involves billing a sick visit in addition to a well visit. You can bill for both if significant extra work is done, according to CPT. In the introduction to the preventive medicine services codes (99381-99397), CPT states, "If an abnormality/ies is encountered or a preexisting problem is addressed in the process of performing this preventive medicine evaluation and management service, and if the problem/abnormality is significant enough to require additional work to perform the key components of a problem-oriented E/M service, then the appropriate office/outpatient code 99201-99215 should also be reported." Consequently, you should attach modifier -25 to the office/outpatient code.

Preventive Medicine Service and Procedure

Pediatricians frequently see patients for scheduled well-visits, and at these visits unscheduled problems may come up requiring a procedure that same day.

For example, an 8-year-old established patient comes in for a preventive medicine service (99393, Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunization[s], laboratory/ diagnostic procedures, established patient; late childhood [age 5 through 11 years]). During the visit, the boy points out a "bump" on his foot. The pediatrician examines it and offers to remove it with cryotherapy (17000*, Destruction [e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement], all benign or premalignant lesions [e.g., actinic keratoses] other than skin tags or cutaneous vascular proliferative lesions; first lesion). The boy's guardian agrees, and the pediatrician applies the liquid nitrogen, saying that the wart will probably fall off within one week. You should code the case with 99393-25 and 17000. Link diagnosis code V20.2 (Routine infant or child health check) with 99393, and link 078.19 (Other specified viral warts) with 17000.

Technically, you could also bill a problem visit (99211-99215). But Joan Gilhooly, CPC, CHCC, of Medical Business Resources, a Deer Park, Ill.-based coding, compliance and reimbursement consultancy, does not believe enough work would be involved in the E/M portion of the wart removal. Therefore, she recommends billing only 99393 and 17000.

Normally, a wart removal code would be accompanied by an E/M office visit code, Gilhooly admits. In this case, 99393 would cover the minimal work involved in diagnosing the wart and deciding to treat it.

The only time a wart removal code would be used alone, with no E/M, is for a re-treatment. For example, if the child has to return because the wart did not fall off in the allotted time period and the pediatrician reapplies the liquid nitrogen. In that case, bill only 17000, with no E/M code.

Another example of billing a procedure in addition to a well visit is cerumen removal (69210, Removal impacted cerumen [separate procedure], one or both ears). A 4-year-old comes in for a preventive medicine services visit. The mother mentions that her child does not seem to hear well. The doctor detects impacted cerumen and removes it, billing 69210. Although modifier -25 is not technically required because 69210 is not a starred procedure and not bundled with 99392 ( early childhood [age 1 through 4 years]), you should still use the modifier. Payers may require it to differentiate between the well visit and the procedure, Callaway says. Use diagnosis code V20.2 for 99392-25, and 380.4 (Impacted cerumen) for 69210.

In the Medicare program, 69210 is viewed as a minor surgical procedure, which means it requires modifier -25, Callaway says. Most managed care payers would expect to see modifier -25 appended to the E/M service code.

Preventive Medicine,Sick Visit and Procedure

Sometimes, you justifiably can bill for a preventive medicine services visit, a sick visit and a procedure. For example, an 11-year-old boy is scheduled for a checkup on Monday. The preceding Thursday evening, the boy made a diving catch at a baseball game, and over the weekend his wrist began to ache. At the physical, the patient pointed out the pain. After the physical, the physician performed an x-ray of the wrist and discovered a greenstick fracture of the radius. As a result, the physician performed the definitive fracture care, and no referral to an orthopedist was necessary.

In this case, Gilhooly says, bill for the preventive medicine services visit (99393), the evaluation of the wrist (probably 99212 or 99213), the x-ray (73100, Radiologic examination, wrist; two views), and the fracture care (25500, Closed treatment of radial shaft fracture; without manipulation). You should link diagnosis codes V20.2 to 99393, 813.xx (Fracture of radius and ulna) to 99211-99215, 729.5 (Pain in limb) to 73100, and 813.xx to 25500. In addition, append modifier -25 to the established patient E/M code.

Sick Visit and Procedure

In another example, a child came in for a scheduled appointment for repeat treatment on a resistant wart. The child also has had a head cold for a week, and now complains of sinus pain. Report 17000 for the wart destruction, and an office visit (99211-99215) with modifier -25 appended for services associated with addressing the child's respiratory infection. Link diagnosis code 078.19 to the wart removal, and 465.9 (Acute upper respiratory infections of multiple or unspecified sites; unspecified site) to the office visit.

Same Diagnosis for Procedure and Office Visit

A child with a laceration on the calf after a fall reports to the pediatrician. The physician examines the injury and determines that there is no nerve or tendon damage. Then, he or she sutures the laceration. In this case, you should bill an E/M (99211-99215) code for the examination and medical decision-making with modifier -25 appended. Bill 12001-12004, depending on the size of the laceration, for the repair. Link diagnosis code 891.0 (Open wound of knee, leg [except thigh], and ankle; without mention of complication) to the E/M service, and the same diagnosis to the laceration repair code.

"There's a misconception that in the office setting, if you do a laceration repair, you shouldn't also bill for an E/M service," Gilhooly says. "But you should bill for both because you need to perform both."

Billing a laceration repair code alone would be appropriate, however, if a patient had a small superficial laceration of the cheek repaired with Dermabond. In this case, you would code 12011* (Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less) with diagnosis 873.41 (Other open wound of head; face, without mention of complication; cheek).

In another example, a mother brings in a 3-year-old with what she describes on the telephone as a "dislocated elbow." In fact, it is nursemaid elbow (832.0x) and quickly reduced by the pediatrician. You should bill 24640* (Closed treatment of radial head subluxation in child, nursemaid elbow, with manipulation). No additional E/M service is necessary unless additional trauma needs to be addressed, such as a head injury. It would be justifiable to bill an E/M visit for the examination of the extremity, but many pediatricians do not because the E/M service is so minimal.

Some pediatricians do not like to bill for some of these minor procedures such as nursemaid elbow or cerumen removal, saying that they are performed quickly. "It doesn't matter how long it takes you to do something; if you do it, you should bill for it," Gilhooly says. "The issue is risk, not time."