Pediatric Coding Alert

Sometimes, simple repairs require complicated coding solutions.

Here’s an all-too-familiar summer scenario: while running and diving off a wooden dock, a 7-year-old boy steps on a rusty nail and opens up a 1.2 cm wound on his left foot. Rather than taking him to the emergency room, his father decides to bring him to your office, where your pediatrician treats the patient.

As simple as this case study appears on the surface, it does present some coding challenges. Here are some of the issues you may have to deal with if such an encounter crosses your desk.

Code Procedure or E/M?

The first issue you will have to negotiate in this case study is how to code the service the pediatrician has provided to the patient. “For medical necessity, the provider needs to determine if the wound just needs to be cleaned and bandaged or needs suture,” says Donelle Holle, RN, president of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana.

In this scenario, if the pediatrician decided that the wound did not need suturing, you would probably have a solid case for coding 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 …), assuming the patient is established to your practice.

Why? Medical decision making (MDM) in this scenario would only rise to a straightforward level based on the patient presenting with a single, self-limiting problem; the treatment for that problem creating minimal risk of complications or morbidity to the patient; and there being minimal or no data for your pediatrician to review or analyze.

If your pediatrician does perform a simple closure, there are several alternative routes you might take to code this encounter.

Closure with adhesive strips: Per CPT^®, this would be reported with an appropriate office/outpatient evaluation and management (E/M) code rather than a wound repair code. For patients covered by Medicaid, you would use HCPCS code G0168 (Wound closure utilizing tissue adhesive[s] only) instead, which is “considered a packaged supply code with the proper laceration repair codes and cannot be billed separately,” Holle notes.

Closure with sutures: You would report 12001 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less) for the simple laceration repair.

Code Procedure and E/M?

If provider documentation shows that your pediatrician went above and beyond the simple laceration repair, you may be able to make a case for coding a low-level, established-patient E/M in addition to the 12001. “For medical necessity, if the pediatrician determines the wound just needs to be cleaned and bandaged or needs suture, if there is any infection in the foot, and if the provider needs to assess if the patient has been properly vaccinated against tetanus,” according to Holle, you may have a case for coding the 99212 as well as the 12001, appending 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 indicate that the E/M service is separate and significant.

“If this were a new patient, a separate E/M would also be appropriate, as the provider would have no knowledge of other health issues prior to making the decision to do the repair,” advises Melanie Witt, RN, CPC, MA, an independent coding expert based in Guadalupita, New Mexico. In this case, though, you would use 99202 (Office or other outpatient visit for the evaluation and management of a new patient …) with modifier 25 attached instead.

Check for Tetanus Immunization

This encounter also presents a good opportunity for the pediatrician to check the child’s immunization schedule to determine if they are current with their tetanus vaccine. If the patient is following the Centers for Disease Control and Prevention (CDC) immunization guidelines (found at www.cdc.gov/vaccines/schedules/downloads/child/0-18yrs-child-combined-schedule.pdf), then there should be no need to administer a vaccine; if not, and as the patient is over the age of 7, one of two vaccine products would apply here:

• 90714 (Tetanus and diphtheria toxoids adsorbed (Td), preservative free, when administered to individuals 7 years or older, for intramuscular use)
• 90715 (Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), when administered to individuals 7 years or older, for intramuscular use).

“Since inadequate protection against diphtheria and tetanus often occur together, Td is the preferred vaccine, not the tetanus toxoid alone. The Tdap, which includes vaccination for whooping cough, should be used in place of Td in patients who have an indication. The other tetanus-containing vaccines would only be given if the patient needed immunization against the flu, polio, or hepatitis B at the time of the injury,” Witt advises.

Don’t forget: Remember to use 90471 (Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid)) for the vaccine administration. And if your provider counseled the patient and/or parent on the risks and benefits of the vaccine, you would use 90460 (Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional …) for the administration code.

Add the Dx

Depending on the kind of wound your provider reports, you could code S91.332A (Puncture wound without foreign body, left foot, initial encounter) or S91.312A (Laceration without foreign body, left foot, initial encounter). You may also have to code any wound infection should your provider’s notes indicate it, as the S91 codes come with Code Also instructions for you to do so.

You might also use secondary codes such as W45.0XXA (Nail entering through skin, initial encounter). Even though “there is no national requirement for mandatory ICD-10 external cause code reporting, you would use external cause codes if your provider ‘is subject to a state-based external cause code reporting mandate or these codes are required by a particular payer,’ according to ICD-10 guidelines,” says Witt.