Pediatric Coding Alert

Pediatricians should be aware that providing and billing for procedures is a lucrative aspect of practice often relegated to surgical specialists. As they provide these procedures, appropriate coding and attention to National Correct Coding Initiative (NCCI) edits becomes more important.

Pediatricians who perform small lesion removals requiring layered or complicated closure can no longer bill for the closure, based on the NCCI Edits . The first-quarter 2003 version 9.0, effective Jan. 1-March 1, also bundles two blood count codes.

According to Medicare, NCCI edits take precedence over any guidelines in CPT. Although private payers are not required to observe the edits, many do, either in whole or in part. Check with individual payers before billing.

Lesion Closure Now Includes Excision

NCCI contradicts CPT instructions by bundling intermediate (12031-12057, Layer closure of wounds ...) and complex (13100-13153, Repair, complex ) repair with benign lesion excision (11400, 11420, 11440), the smallest lesion excision in each category. CPT 2003 added language to the "excisionbenign lesions" subsection: "For excision of benign lesions requiring more than simple closure, i.e., requiring intermediate or complex closure, report 11400-11466 in addition to appropriate intermediate (12031-12057) or complex closure (13100-13153) codes." The edits render this CPT instruction obsolete. On the other hand, you would not necessarily see an intermediate or complex closure on a 0.5-cm-or-smaller lesion, says Barbara Cobuzzi, MBA, CPC, CPC-H, a coding and reimbursement specialist and president of Cash Flow Solutions, a medical billing firm in Lakewood, N.J.

Pediatric coders should follow NCCI's instructions and only code small, benign lesion excision and an intermediate or complex repair separately with the appropriate modifier. For instance, a pediatrician removes a 0.5-cm lesion requiring intermediate repair from a child's hand and a 0.3-cm lesion from his leg. For the hand repair and excision, report 12041* (Layer closure of wounds of neck, hands, feet, and/or external genitalia; 2.5 cm or less), which includes the excision. For the neoplasm excision from the leg, assign 11400 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms or legs; excised diameter 0.5 cm or less) appended with modifier -59 (Distinct procedural service) to indicate a separate anatomic site.

Two CBCs,One Code

In addition to the lesion excision bundling, NCCI now prevents coders from billing 85025 (Blood count; complete [CBC], automated [Hgb, Hct, RBC, WBC and platelet count] and automated differential WBC count) with 85027 (... complete [CBC], automated [Hgb, Hct, RBC, WBC and platelet count]). Previously, NCCI allowed you to bill these codes together with a modifier under appropriate circumstances.

"You wouldn't perform these two procedures in the same session," says Daniel S. Fick, MD, director of risk management and compliance for the College of Medicine faculty practice at the University of Iowa in Iowa City. "But sometimes the physician will perform a complete blood count (CBC) to determine the different types of white cells and their ratio (85025) on a sick patient and then later in the day perform a CBC to determine the total count (85027)."

In such a case, you could previously report 85025 and 85027 appended with modifier -59 (Distinct procedural service). But now that NCCI 9.0 has changed the modifier indicator from a "1" to a "0," you can no longer use a modifier to break the edit. Therefore, payers that follow NCCI will bundle 85027 into 85025 and pay for 85025 only.