Pediatric Coding Alert

Question: Our provider administered an ear lavage to remove impacted cerumen in one of our patients. The pediatrician also administered a steroid injection (J0702) to reduce inflammation. When we billed for the encounter, we billed for a level-four evaluation and management (E/M) encounter for an established patient with modifier 25, but we were denied the injection administration fee (96372) because it is bundled into the cerumen removal (69209). This seems strange, as there is no connection between the injection and the removal. What are we doing wrong? Do we have to attach modifier 59 or 51 to show that the procedures are separate?

New Mexico Subscriber

Answer: You have identified the problem in your documentation. As you say, it is not with the 99214 (Office or other outpatient visit for the evaluation and management of an established patient …), as you have correctly attached modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to indicate that the E/M is separate from the procedures.

The problem, as you point out, lies in the procedure bundling. While it may seem obvious that you documented the 96372 (Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular) in conjunction with the J0702 (Injection, betamethasone acetate 3 mg and betamethasone sodium phosphate 3 mg), your payer is viewing this differently.

That’s because the 96372 is a column 2 code for 69209 (Removal impacted cerumen using irrigation/lavage, unilateral) according to National Correct Coding Institute (NCCI, or CCI) edits. Injection administration typically bundles into most surgical procedures, but as it has a modifier indicator of 1, you can easily unbundle it with the correct modifier.

The question then becomes which modifier is appropriate. You mention two — modifier 59 (Distinct procedural service) and modifier 51 (Multiple procedures) — and while 51 may seem appropriate, it is usually appended to document:

• Different procedures performed at the same session;
• A single procedure performed multiple times at different sites; or
• A single procedure performed multiple times at the same site.

However, modifier 59 is more appropriate in this scenario, as you are telling your payer that the injection is separate from the ear lavage and that it was not performed as a part of the lavage service.

So, you would code the whole encounter as 99214-25, J0702, 96372-59, and 69209.