Pediatric Coding Alert

Question: Our office manager wants to charge for an office/outpatient evaluation and management (E/M) visit as well as a destruction code for removing a patient’s warts. But can you charge for the E/M if the visit is only for the destruction?

AAPC Forum Participant

Answer: Coding for the procedure and the E/M always depends on the circumstances of the encounter. Consider the following scenarios, then apply them to your own circumstances to decide.

Scenario 1: An established patient arrives at your office with their parent who tells you the patient has four warts behind their left ear that need to be removed. Your pediatrician examines the area behind the patient’s ear, agrees with the parent, and removes them with salicylic acid. The pediatrician performed no other work during the encounter.

Code choice: In this case, you would bill 17110 (Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions). As no other work was performed at the encounter, you cannot bill an office/outpatient E/M in this situation; the evaluation and management of the condition is folded into the work involved in removing the warts.

Scenario 2: An established patient arrives at your office with their parent who tells you the patient has an ear infection. The pediatrician examines the ear, and in the process, discovers four warts behind the patient’s left ear. The pediatrician diagnoses the ear infection and prescribes an antibiotic, then removes the warts with salicylic acid.

Code choice: This time, you would be justified in billing for an office/outpatient E/M and the wart destruction because the pediatrician discovered the warts during an examination for a separate condition. Your claim would consist of a low-level office/ outpatient E/M — likely 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making …) — along with the 17110. You would also add 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 the E/M to show that it was significant and separate from the destruction.

Other possibilities: Depending on details, you might also be able to bill for the destruction and an E/M if the warts were discovered during a well-child visit, or during a new patient evaluation. The key is to make sure you document work your pediatrician performed above and beyond the evaluation of the warts and their destruction. But you should consult payer guidelines for such exceptions before doing so.