Pediatric Coding Alert

Coding an E/M service with a minor procedure never ceases to stump even the most confident coding experts, so follow five tips to report these services without losing ethical reimbursement and committing fraud. Report Significant,Separately Identifiable E/M When a pediatrician provides a separate E/M service and a minor procedure during the same visit, you should bill both services and 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. Modifier -25 indicates that the E/M is separate and significant to any minor procedure that the physician also provides on the day of the visit, says Shirley Fullerton, CPC, supervisor of HIM (Medical Records) for the Valley Hospital Medical Center in Las Vegas. "The key words are 'separate' and 'significant,' " she says. Two Diagnoses Are Unnecessary Some insurance companies interpret "significant" and "separate" to mean that you must treat something different, says Susan Callaway, CPC, CCS-P, an independent coding auditor and trainer in North Augusta, S.C. "CPT states that this is not necessary, and Medicare does not require a different diagnosis."

For instance, a 3-year-old child cuts his wrist on the edge of a glass table. He is rushed to the pediatrician's office, and has a 2-cm bleeding laceration. The pediatrician examines the injury and determines that no nerve or tendon damage exists. He also inspects the wound for any glass fragments, which he doesn't find, and sutures the laceration. In this case, you should bill for the laceration repair (12001*, Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]) and the E/M (99212-99215, Established patient office visit) appended with modifier -25. Although there is only one diagnosis open wound (881.02, Open wound of elbow, forearm, and wrist; without mention of complication) the E/M is allowable because the physician performed a separate service to assess the injury's severity. A second diagnosis, however, helps processing claims for an E/M with a minor procedure. You should also report the E codes, which are for statistics, not reimbursement. For the fall, assign E888.0 (Fall resulting in striking against sharp object) and E920.8 (Other specified cutting and piercing instruments or objects). E/M Must Be Medically Necessary Because CPT doesn't require a second diagnosis, many practices want to charge an E/M attached with modifier -25 in addition to cerumen removal (69210, Removal impacted cerumen [separate procedure], one or both ears) with an impacted cerumen diagnosis (380.4) only. "Cerumen removal doesn't pay well," says Barbara Cobuzzi, MBA, CPC, CPC-H, a coding and reimbursement specialist and president of Cash Flow Solutions, a medical billing firm in Lakewood, N.J. When cerumen [...]