Primary Care Coding Alert

Question: We recently saw a young child with chicken pox. While the patient, his mother and his brother were waiting for the examination, the brother and patient were wrestling on the exam table. The patient fell and cut his head, which required two stitches. How should we bill this? Should we submit a claim for the chicken pox exam and the stitches?

Ohio Subscriber

Answer: Certainly, you should submit a claim to the patient's insurance for the chicken pox (052.9, Varicella without mention of complication).

The other issue is problematic. The patient's insurance may pay, but your practice's liability policy may cover this. You should fill out an incident report and contact your liability insurance company to determine how you should proceed. You should handle this situation with a great deal of diplomacy, in case the patient's family pursues a personal-injury lawsuit. Although you may feel you were not responsible for the accident, the patient's family may nonetheless take legal action.

If you submit a claim to the patient's insurer, you should report 959.01 (Injury, other and unspecified; head injury, unspecified), 959.09 ( injury of face and neck) or 873.8 (Other and unspecified open wound of head without mention of complication). You should also report the stitches with a code from the 12001-12021 series, which describes simple repairs. Choose the appropriate code based on the length of the wound. In addition, you should 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 the E/M code to identify it as a significant and separately identifiable service.