Pediatric Coding Alert

Test your coding knowledge. Determine how you would code this situation before looking at the box below for the answer.

Question: Can we bill for an office visit in addition to a catheterization?

Tennessee Subscriber

  Answer: Yes, but you must provide and document a significant and separately identifiable service in the office visit.

Because catheterization is a starred procedure, CPT Codes specifically allows it to be billed with an office visit, providing the requirements of modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) are met. You must perform the elements of an E/M service history, examination and medical decision-making to bill for it. The catheterization doesnt include these elements.

A separate diagnosis is not required: CPT specifically allows starred procedures and an E/M service to have the same diagnosis code.

Report 53670* (catheterization, urethra; simple) for the catheterization. For the E/M service, bill the appropriate established-patient E/M code (99212-99215) with modifier -25 appended.

For example, a female infant suffers from fever and fussiness. The physician catheterizes her to obtain a urine specimen for a culture. Before deciding that catheterization is a proper diagnostic tool, the physician must consider many other possibilities and likely performs other diagnostic procedures as well. The greater the number of diagnostic options, the stronger the case for billing an E/M service in addition to the catheterization.

Catheterizing a child requires skill and time much more so than catheterizing an adult. Yet there is no CPT code specific to pediatric catheterization. Do not bill 53675* (catheterization, urethra; complicated [may include difficult removal of balloon catheter]) to reflect the extra time spent with a child. Rather, consider this extra effort counseling time: You are trying to persuade a reluctant patient to accept a necessary procedure. If more than 50 percent of the encounter time is spent on counseling including the discussion to convince the child to accept the procedure you may bill the E/M service based on time.