Pediatric Coding Alert

Pediatricians lose revenue if they do not bill for minor procedures done during an office visit. They can't always bill for these procedures and the E/M together it depends on the procedure, the reason for the visit, the available codes and the circumstances. Most of the time a minor procedure and office visit can be billed together, says Richard H. Tuck, MD, FAAP, founding chairman and member of the AAP coding and reimbursement committee and the AAP's AMA review update committee (RUC). The physician must perform a significant, separate procedure from the office visit to charge for both.
 
"Generally speaking, when a physician performs a procedure on the same visit as an E/M service, both should be billed using modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) attached to the E/M code," says Joel Bradley, MD, FAAP, CPT adviser for the AAP. CPT states that a different diagnosis is not required for each. In fact, the symptom or condition that prompted the E/M service can be the same as the procedure.
 
Reimbursement may be denied even though a different diagnosis is unnecessary. Be prepared to appeal. Your documentation should differentiate the work for the E/M service from the procedure. Record the office visit and the procedure on two separate notes or pages in the chart.
 
Knowing when to bill an E/M in addition to the minor procedure is demonstrated in eight examples:
 
Note: Add modifier -25 to the E/M code to signify significant, separate work whenever the E/M is warranted.

1. Peak Flow or Spirometry
 Hand-held peak flow readings lack a code because they are included in the E/M. The payer will bundle any provider work associated with a peak flow into the E/M.
 
If you perform complete spirometry with a graphic record, code 94010 (spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation). An E/M service is warranted, Tuck says. 

2. Pelvic Exam
 There is no code for a pelvic exam, so there is no way to bill for it in addition to an E/M service. If, however, a teen-age girl comes in for a well visit and has a medical problem necessitating a pelvic exam, bill for the preventive-medicine service, CPT 99384 (new patient, ages 12-17), 99394 (established patient, ages 12-17), 99385 (new patients, 18-39) or 99395 (established patients, 18-39), in addition to the office visit, 99201-99205, 99212-99215, with modifier -25 appended to the office visit. A routine pelvic exam is included in a well visit. A pelvic exam that addresses a significant medical problem is not bill additionally, Tuck says. (See Pediatric Coding Alert August 2001 for more on coding pelvic exams.)

3. Nebulization
 Always bill for an E/M in addition to nebulization. Bill 94640 (nonpressurized inhalation treatment for acute airway obstruction) if no training is provided, or 94664 (aerosol or vapor inhalations for sputum mobilization, bronchodilation, or sputum induction for diagnostic purposes; initial demonstration and/or evaluation) if it is the first time the patient or parent is being trained in the use of the nebulizer. "Separate billing is justified because the office visit is a separate service," Tuck says. The pediatrician must do more than just provide nebulization: If a child is wheezing, a thorough examination is required and medical decision-making is involved.

 Laceration repair performed by a primary care pediatrician (12001*-12004*, 12011*-12013*) would almost always call for coding a separate office visit as well, Bradley says. "Clearly, when a patient comes in with a laceration after an accident, and requires a detailed history and physician exam to look for other injuries, the E/M and the laceration repair should be billed together." Attach modifier -25 to the E/M code.

5. Catheterization
 Catheterization (53670*, catheterization, urethra; simple) also warrants a separate E/M service, Tuck says. The diagnosis is usually the same for both the catheterization and the E/M service. "Usually, you do a catheterization in a child when you are considering a diagnosis of urinary tract infection," he explains. Catheterization can also determine the cause of acute febrile illness, or the cause of dysuria.

6. Cerumen Removal
 Cerumen removal (69210, removal impacted cerumen [separate procedure], one or both ears) sometimes warrants a separate E/M service, Tuck says. A child complains of pain, or the mother noticed a diminution in hearing. The pain examination finds impacted cerumen.
 
Tuck says that if before the removal the pediatrician performs a history and an examination, evaluating the upper airway, the nose, the pharynx, the chest  not just the ear then the visit involves more than removing the cerumen and warrants an E/M visit to be billed as well.

7. Wart Treatment
 
Wart treatment (17110, destruction by any method of flat warts, molluscum contagiosum, or milia; up to 14 lesions) sometimes justifies a separate E/M, Tuck says. "If the appointment is made to have warts treated, and I look at them, say they're warts, and remove them with liquid nitrogen, I don't bill an E/M service in addition," Tuck says. If the child comes in for a well visit, and some warts are discovered, then Tuck bills for the wart removal separately, appending modifier -25 to the well visit.

8. Nursemaid Elbow
 
Tuck would rarely bill a separate office visit for reducing nursemaid elbow (24640*, closed treatment of radial head subluxation in child, nursemaid elbow, with manipulation). The history and exam are usually brief, and the pediatrician performs the reduction immediately. For example, a child can't move his arm, and the mother says she pulled him out from under the bed  and it's clear that the problem is subluxation of the radial head, there is no reason to bill an E/M in addition, Tuck says. However, if the child fell down the stairs and may have bumped his head, a separate E/M visit is warranted because an extensive exam and medical decision-making are involved.