Pediatric Coding Alert

Question: A boy comes into our office with a ring stuck on his finger. The doctor administers a nerve block prior to cutting the ring off. The encounter takes more than one hour. Which procedure and diagnosis code should I use?

New York Subscriber

Answer: No procedure code exists for foreign-body removal without incision. So, the only surgery code that you should report is 64450 (Injection, anesthetic agent; other peripheral nerve or branch) for the nerve block. Include the removal work in the E/M service.
 
You should report the appropriate-level office visit code ( CPT 99201 - 99215 , Office or other outpatient visit for the evaluation and management of a new or established patient ...) for the E/M service. Append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to 99201-99215 to indicate the office visit is a significant, separately identifiable service from the nerve block. You may also report prolonged services for any additional time that the pediatrician spends face-to-face with the patient beyond the usual time CPT includes in the selected service level.

Suppose your pediatrician documents 60 face-to-face minutes with the patient. She performs and documents a level-three established patient office visit (99213, ... an expanded problem-focused history, expanded problem-focused examination, and medical decision-making of low complexity ... physicians typically spend 15 minutes face-to-face with the patient and/or family). CPT indicates 99213 typically takes 15 minutes. Therefore, you may use prolonged service code +99354 (Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service [e.g., prolonged care and treatment of an acute asthmatic patient in an outpatient setting]; first hour [list separately in addition to code for office or other outpatient evaluation and management service]) to account for the additional 45 face-to-face minutes.

Choose the E/M ICD-9 code based on whether the ring caused an injury. Select 915.6 (Superficial injury of finger[s]; superficial foreign body [splinter] without major wound and without mention of infection) for no injury or 915.8  (... other and unspecified superficial injury of fingers without mention of infection) for a superficial injury. In summary, you would report the claim with 64450, 99213-25, 99354.