Pediatric Coding Alert

Remember global periods for procedures to ease modifier choice.

Evaluation and management (E/M) services that lead to a procedure can perplex coders when it comes time to choose the proper E/M modifier.

Solution: We got some expert information on what the encounter notes might look like on claims with a procedure plus an E/M with modifier 57 (Decision for surgery) or 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) appended.

Check out these case studies from Donelle Holle, RN, President of Peds Coding, Inc, and a healthcare, coding, and reimbursement consultant in Fort Wayne, Ind., to see what encounters with each of these E/M modifiers might look like:

Modifier 57 Example

The encounter: An 8-year-old established patient presents with an injury to her left shoulder. She says she was running when she slipped, tried to stop fall with her arms, and fell on her left shoulder. The patient complains of pain on the left clavicle area and left upper chest area; the pediatrician notes swelling and a large bruise on the shoulder. The patient cannot raise her arm without pain, but she doesn’t have a fever. During the examination, the patient is alert but in obvious pain. Her range of motion is limited due to sharp pain. Notes indicate an expanded problem focused history and exam, along with moderate medical decision making (MDM), during the E/M service.

An x-ray reveals a non-displaced left sternal end clavicle fracture. After explaining the need for closed treatment to the patient and her parents, the pediatrician performs closed treatment of the fracture without manipulation and applies a clavicle splint to stabilize the fracture, which the patient tolerates well. The physician explains to the patient how she should care for the injury while in the splint, orders pain medication, and schedules the patient for a two-week follow-up visit unless the pain does not decrease. 

The coding: Since the pediatrician performed a procedure that has a “major” (90-day) global period, this is a prime example of modifier 57 coding. On the claim, you would report:

• 23500 (Closed treatment of clavicular fracture; without manipulation) for the fracture care
• 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity…) for the E/M service
• Modifier 57 appended to 99213 to show that the pediatrician performed the E/M separately before deciding the patient required a major procedure
• M25.512 (Pain in left shoulder) appended to 99213 to represent the reason for the E/M service.
• S42.012A (Anterior displaced fracture of sternal end of left clavicle, initial encounter for closed fracture) appended to 23500 and 99213 to represent the patient’s injury.
• W01.0XXA (Fall on same level from slipping, tripping and stumbling without subsequent striking against object, initial encounter) appended to 23500 and 99213 to represent the reason for the patient’s fall.

Modifier 25 Example

The encounter: An established 8-year-old patient presents with a red area on her left calf that her mother says has “fluid” in it. Her mother says the girl hurt her leg a week ago, and now the area is red and seems to be getting much worse. The patient also has a slight fever.

During examination, the patient is alert and active, with an area of induration on her left calf. The area appears infected with pus, but there are no other concerning areas on the skin. Notes indicate an expanded problem focused history and exam, along with low MDM, during the E/M service. The pediatrician diagnoses cellulitis of the patient’s lower left leg.

After explaining to the patient and her mother the need for incision and drainage (I&D), the pediatrician uses a small-gauge needle to open the wound and drain a large amount of serous fluid. The pediatrician then dresses the wound with antibiotic ointment and sterile dressing, which the patient tolerates well. The pediatrician also obtains a culture of the fluid for laboratory analysis.

After the I&D and dressing, the pediatrician instructs the patient and her mother to clean the wound with astringent soap, and also prescribes antibiotic medication.

The coding: Since the pediatrician performed an E/M prior to a procedure with “minor” (10-day) global period, this is a prime modifier 25 scenario. On the claim, report:

• 10060 (Incision and drainage of abscess [e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia]; simple or single) for the I&D
• 99213 (… an expanded problem focused history; an expanded problem focused examination; low medical decision making) for the E/M service 
• Modifier 25 appended to 99212 to show that the pediatrician performed a significant, separately identifiable E/M before the I&D
• L03.116 (Cellulitis of left lower limb) appended to 10060 to represent the final diagnosis
• S80.922A (Unspecified superficial injury of left lower leg, initial encounter) appended to 99213 to represent the patient’s wound.