Pediatric Coding Alert

Combat E/M and catheterization denials with documentation, diagnoses and modifier

When billing for office visits that result in urine catheterizations, you may face denials for the E/M, the catheterization and/or the catheterization kit. But you can recoup payment when you follow these four steps: 1. Document Separate E/M You should bill for an office visit (99201-99215, Office or other outpatient visit for a new or established patient ...) in addition to urine catheterization (CPT 51701 , Insertion of non-indwelling bladder catheter [e.g., straight catheterization for residual urine]) if  documentation supports a separately identifiable E/M service. Usually, you will perform a history, examination and medical decision-making prior to catheterization.

Problem: Code 51701 is no longer a starred procedure and is now a zero-day global procedure. So, payers may include a minor pre-, intra-, and post-E/M service with the catheterization.

Solution: Show that the E/M service led you to decide that the child needed surgery.

Here's how: Write a separate office and procedure note. If you have to appeal for office visit payment, separate documentation will substantiate that you couldn't perform the procedure without the office visit.

Illustration: A 9-month-old girl presents with fever and a bagged urine specimen that suggests infection. You decide to perform a urine catheterization to obtain a sterile urine sample for urinalysis and culture.

The office note should describe the E/M service. Include the child's history of present illness, review of systems and your physical examination findings, says Michael A. Ferragamo Jr., MD, FACS, clinical assistant professor of urology for the Health Science Center at the State University of New York in Stony Brook. Add your assessment, such as "fever of unknown origin" (780.6, Fever). Then, note your plan, such as "Need to do a urine catheterization to obtain sterile urine sample for urinalysis and culture."

Next, you should write a separate paragraph or use a different sheet for your procedure note. After recording your pre- and post-diagnoses and your findings, record your final assessment and plan, Ferragamo says. "For instance, in your final assessment, you may determine: Child has a urinary tract infection (599.0)," he says. Your plan would then describe your antibiotic and treatment regime.

Listing your assessment and plan twice shows the payer that you didn't have a final diagnosis at the E/M service's conclusion. Therefore, the office visit led to your decision to perform the catheterization.

2. Report Separate Service, Procedure Diagnosis Using different ICD-9 codes with the office visit and the catheterization will also support billing both the service and the procedure. "Insurers like having separate diagnoses for 99201-99215 and 51701," Ferragamo says.

Example: A pediatrician saw a child at 10:30 p.m. for acute urinary retention due to perineal pain after a straddle injury. The insurer paid only for the established patient [...]