Pediatric Coding Alert

Question: At a preventive medicine service, a pediatrician found that the infant had a hair wrapped around his toe. The physician removed the hair. What diagnosis code should I use?

New Jersey Subscriber

Answer: You should report the injury that the hair tourniquet caused based on the toe's condition. If the pediatrician documented that the toe was infected, use 917.9 (Other and unspecified superficial injury of foot and toes, infected). For an injury without infection, assign 917.8 (Other and unspecified superficial injury of foot and toes without mention of infection). To identify the injury's cause, report E928.4 (External constriction caused by hair).

If documentation supports the treatment of the injury, including removal and cream and/or antibiotic treatment for an infected toe, you should report a problem-oriented service (such as 99212 or 99213, Office or other outpatient visit for the evaluation and management of an established patient ...) in addition to the preventive medicine service (such as 99391, Periodic comprehensive preventive medicine reevaluation and management of an individual ...; infant [age younger than 1 year]).

To indicate the office visit is significant and separately identifiable from the well check portion, append modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to 99201-99215. Link the preventive medicine service to V20.2 (Routine infant or child health check) and the problem-oriented portion to 917.x and E928.4.