Pediatric Coding Alert

On occasion a pediatrician attempts a procedure but, due to unusual or unforeseen circumstances, is unable to complete the service, or must spend extra time to do so. Many physicians dont like to bill for a procedure if they havent been able to complete it successfully, but pediatricians who dont bill for incomplete or difficult procedures are cheating themselves of reimbursement they have legitimately earned.

For example, CPT 62270 * (spinal puncture, lumbar, diagnostic) was created for all ages, but the relative value units assigned to this code do not take into account the circumstances a pediatrician may confront, such as a frightened 6-year-old with a high fever who begins screaming and writhing wildly each time the doctor approaches with a needle. Performing a spinal tap under
these circumstances requires additional effort, and even if the procedure is not completed successfully or with the desired results, the pediatrician is entitled to payment.

Gain Reimbursement for Extra Work

According to CPT, modifier -22 (unusual procedural services) may be appended when the service(s) provided is greater than usually required for the listed procedure. Although this modifier may result in added reimbursement, it also requires careful documentation.

If, for instance, you spend extra time and work doing a spinal tap, you should bill 62270* with modifier -22, but you need to tell the insurance company exactly how much extra work you did, explains A.D. Jacobson, MD, FAAP, who practices with Pediatric Associates, a four-pediatrician practice in Phoenix. This means including the progress notes to explain why the procedure was difficult and how much time it took, he says.

My recommendation is that you shouldnt use modifier -22 unless you can document that you did at least 50 percent additional work, agrees Susan Callaway, CPC, CCS-P, an independent coding consultant based in Augusta, S.C. Include a description of what happened the number of sticks required, for example and a summarizing statement that covers time. The summary could say something like: I usually perform a spinal tap in 20 minutes, but in this case it took one and one-half hours.

When billing a claim with modifier -22, be sure to request an additional fee typically about 20 to 30 percent, depending on the difficulty of the procedure and the level of supporting documentation. The insurer will review the documentation and decide what compensation above and beyond the customary amount is justified.

Use Modifier -53 for Discontinued Procedures

Under extenuating circumstances, including those that threaten the well-being of the child, the pediatrician may choose to discontinue a procedure. This may be reported by appending modifier -53 (discontinued procedure) to the procedure code. In the earlier example of the writhing 6-year-old, for instance, the pediatrician may attempt to perform a spinal tap but fail to introduce the needle fully. The pediatrician can still bill 62270*, Callaway explains, but only if modifier -53 is added.

Some physicians argue that an incompleted procedure means you should be paid more. If you fail at a spinal tap, a catheterization or a venipuncture, it usually means you made multiple attempts, says Richard H. Tuck, MD, FAAP, a member of the American Academy of Pediatrics coding and reimbursement committee who practices in Zanesville, Ohio. Incomplete procedures must always be billed with modifier -53, but additional compensation may be appropriate in some instances, even if the procedure did not produce the desired results.

Fully introducing the needle during a spinal tap but failing to obtain fluid could justify the use of modifier -22 if the child is especially uncooperative (and documentation supports the claim). If the child is cooperative, however, and the pediatrician has no problem introducing the needle but simply cannot obtain fluid, he or she may not append modifier -22.

Note: Depending on circumstances, modifier -53 claims may result in lower compensation. Just as with modifier -22 claims, insurers will review the documentation to determine payment. Use of modifier -53 does not automatically lead to reduced compensation, however.

Coding Unsuccessful Procedures

In some cases, as illustrated above, the pediatrician may complete the procedure but without the desired results. Could the pediatrician who performs a spinal tap without obtaining fluid still bill 62270*? Jacobson says yes. I would bill for it, because I did the work its still a completed procedure. In another example, the pediatrician may perform urinary catheterization (53670*, catheterization, urethra; simple) but is unable to obtain urine. This may be because the child has anuria, Jacobson explains. It may be because something is anatomically wrong. That doesnt mean you shouldnt be paid. In either of these examples the pediatrician should bill the appropriate CPT code, with no modifiers attached.

Richard A. Molteni, MD, FAAP, a member of the CPT editorial panel, agrees. He notes that you can bill for a completed procedure even if is not successful, stressing that modifier -53 is appropriate only if you must stop the procedure before completion due to a patient complication or if the patient is not tolerating the procedure.

Referral to Specialist

When the pediatrician refers the child to another physician who is better able to perform the procedure, both the pediatrician and the other physician can bill the service. The specialist would bill a consultation and the procedure because you are actually consulting him, Jacobson says. For example, the pediatrician may send the child to the hospital so a pediatric neurologist can perform the spinal tap.

If both [physicians] perform the procedure, then both can bill, Molteni explains. The pediatrician would usually bill an office visit plus the procedure if the procedure is starred, and the specialist would bill a consultation and the procedure. Both physicians would 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 evaluation and management (E/M) service. Molteni also recommends that both providers append modifier -77 (repeat procedure by another physician) to the procedure code.

Note: Modifiers -76 (repeat procedure by same physician) and -77 may be used for procedures performed on the same day only. For example, a child with persistent fever might undergo two diagnostic spinal taps on the same day. The second tap would be administered to check if the fluid is getting worse or showing signs of a bacterial infection. Any physician from the same practice as the pediatrician who first attempted the procedure would be coded as same physician if he or she performs the procedure at the hospital.

Sometimes another physician within the same practice may be asked to provide assistance. One pediatrician may be particularly good at venipuncture (36400, venipuncture, under age 3 years; femoral, jugular or sagittal sinus, 36405*, venipuncture, under age 3 years; scalp vein and 36406, venipuncture, under age 3 years; other vein), for example. That pediatrician may be called in to perform the venipuncture only. In this case, involving a second pediatrician does not warrant an extra code, Molteni says. Code the encounters as if they are one.

Prolonged Services

Another option for a successful procedure that requires significant additional time without the component of extra work or skill is the prolonged services codes: +99354 (prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service [e.g., prolonged care and treatment of an acute asthmatic patient in an outpatient setting]; first hour [List separately in addition to code for office or other outpatient evaluation and management service]) and +99355 (... each additional 30 minutes [List separately in addition to code for prolonged physician service]).

These are add-on codes that must be appended to the E/M service, not to the procedure code. Prolonged services codes can only be used when a minimum of 30 extra minutes has been spent. This might occur, for example, if the physician needs to obtain a urine specimen to determine whether a urinary tract infection has abated. The visit doesnt merit a high-level E/M code, but the procedure may take an hour to perform something that happens even to specialists, notes Mark Cendron, MD, associate professor of urology and pediatrics at Dartmouth Hitchcock Medical Center in Lebanon, N.H. In this case, the pediatrician could bill 99212 (office or other outpatient visit for the evaluation and management of an established patient) with +99354, in addition to 53670* for the catheterization.

Other codes that pediatricians typically perform, and that may take extra time or work in children, include 36000* (introduction of needle or intracatheter, vein), 30300* (removal foreign body, intranasal; office type procedure), 69200 (removal foreign body from external auditory canal; without general anesthesia), 31500 (intubation, endotracheal, emergency procedure), 43752 (naso- or oro-gastric tube placement, necessitating physicians skill), and laceration repairs 12001*-12057.