Pediatric Coding Alert

Question: A pediatrician evaluates a newborn and then performs umbilical cord granulation. Should I report the service and the procedure? If an insurer denies the E/M, should I use a modifier, such as -25 or -57, on the office visit code?

California Subscriber

Answer: As long as the evaluation is a separately identifiable service from the procedure or leads to the decision for surgery, you should report both the E/M service (99201-99215, Office or other outpatient visit for the evaluation and management of a new or established patient ...) and the cauterization (17250,

Chemical cauterization of granulation tissue [proud flesh, sinus, or fistula]). Choose modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) or modifier -57 (Decision for surgery), based on the following criteria:

You should use modifier -25 when the physician performs a significant, separately identifiable E/M service beyond what he usually performs with the procedure. For example, the mother presents with an infant who has feeding problems. The pediatrician checks the infant's weight and offers the mother breastfeeding tips. The physician also notices excessive healing tissue around the infant's umbilicus and uses silver nitrate to destroy proud flesh. You should report the appropriate-level E/M service, such as 99212, in addition to the granulation cauterization (17250). Append modifier -25 to 99212 to indicate that the evaluation is separately identifiable from the cauterization's pre- and postoperative service. Report the office visit with the presenting problem, such as 779.3 (Feedingproblems in newborn), and the procedure with the associated diagnosis, granuloma (771.4, Omphalitis of the newborn).

When the E/M service results in the decision for surgery, you should instead use modifier -57. Suppose a father complains that the skin surrounding his son's umbilical-cord stump is red and tender. After taking a history of the problem's duration and the parent's cord care, the pediatrician examines the umbilicus area and discovers pink scar tissue and a foul-smelling, yellowish discharge. Based on the history and examination, the physician decides to cauterize the granulation tissue using silver nitrate. Because the pediatrician performs the office visit and the surgery for the same diagnosis and the E/M led to the decision for surgery, you should append modifier -57 to the E/M service, for instance 99212. Submit the procedure with 17250.

Make sure to check your major payers'modifier -57 policies. Some insurers follow Medicare's lead and restrict modifier -57 to major surgeries. In this case, because 17250 is a minor procedure, use modifier -25. Link the discharge symptom (789.9, Other symptoms involving abdomen and pelvis) to 9921x-25, and link the granuloma (771.4) to 17250.