Pediatric Coding Alert

Hint: When you can't immediately identify the problem, 9921x-25 might be in order Gain the confidence to code -- or not code -- an E/M service with a minor surgery by taking this test. Encounters for splinter removal and laceration repair both seem like plausible times to also bill an office visit for preprocedure work. But you know that coding an E/M service isn't automatic: it must be medically necessary and address key components of history, physical examination, and medical decision-making or be based on time spent in counseling and/or coordination of care. Test your coding against these expert-answered scenarios.
Use E/M With Wart the 1st Time, Not 2nd If you know the wart-service rule of thumb, you'll be able to correctly code this scenario: Question 1: A mother points out a spot on a child's hand, which you identify as a wart. After the mother authorizes the procedure, you remove the wart. Should you code an E/M with the wart removal? Answer 1: Yes, says Richard Lander, MD, FAAP, pediatrician with Essex-Morris Pediatric Group in Livingston, N.J. "When you have to evaluate a spot to get to the diagnosis, you should code the E/M service and the procedure." He suggests coding the above scenario with a low-level E/M service, such as 99212-25 (Office or other outpatient visit for the E/M of an established patient, which requires at least two of these three key components: a problem-focused history, a problem-focused examination; straightforward medical decision-making ...; Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service), and 17110 (Destruction [e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement], of benign lesions other than skin tags or cutaneous vascular lesions; up to 14 lesions). Rule: But if the patient returns with another wart that you remove (17110), you shouldn't code an associated E/M, Lander says. "You already know the diagnosis (such as 078.19, Other specified viral warts), so no E/M service code (e.g., 99212-25) would be warranted." The same "diagnosis known = no E/M" rule applies in another situation. "If the mother comes in having diagnosed the wart herself, you confirm the diagnosis and treat it, coding an E/M service becomes less medically necessary," says Richard H. Tuck, MD, FAAP, a pediatrician at PrimeCare of Southeastern Ohio. "It definitely can be a gray area."
Look for 2nd Dx to Support E/M With FBR Although CPT doesn't require different diagnoses to report an E/M service in addition to a procedure, this is a good indication of when an established patient office visit (9921x-25) is appropriate with intranasal foreign-body removal (30300, Removal foreign body, intranasal; office type procedure). Question 2. Suppose a nanny brings a [...]