Pediatric Coding Alert

Even if you don’t perform “surgeries,” you are subject to global surgical package rules.

Myth: Because pediatricians don’t perform surgeries and aren’t typically subject to Medicare regulations, they don’t need to follow surgical global periods when seeing patients.

Reality: Not only do minor procedures have some global periods associated with them, but even services that have “000” global days actually still fall under the global surgical package rules. Therefore, pediatric offices should be just as aware of the global surgical regulations as other specialists.

Consider This Example

A reader recently contacted Pediatric Coding Alert with this query: “We saw a child three times in the past week—on the first visit, the doctor did an incision and drainage (I&D) on an abscess and packed the wound. On the subsequent two visits, the pediatrician repacked the wound and the patient left. What do we report for the two repacking visits? Just an E/M code?”

The reality is that if you report an I&D code such as 10060 (Incision and drainage of abscess [e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia]; simple or single), then any E/M code you use for the next 10 days will be bundled into the initial I&D payment, because these codes have 10-day postoperative periods, says Donelle Holle, RN, pediatric coding consultant and president of Peds Coding, Inc. “This means unless the physician has to repeat the procedure, those visits are inclusive into the procedure.”

On the other hand, Holle adds, if you have a visit for the I&D but the pediatrician finds other issues he needs to address with an E/M service, then you can report the E/M code linked to the other diagnosis code. You would append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the day of a procedure or other service) to the E/M code to demonstrate that it was separate and distinct from the I&D on the first visit.

On the second or any subsequent visit during the global period, if there are other issues found, bill the office visit with a 24 modifier (Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period) to indicate it is not inclusive in the global period. Without the use of the 24 modifier, the visit will bundle as global.

Don’t Be Surprised by Globals

The number of commonly-performed procedures linked to ten-day global periods may surprise you, and include the following, among others:

• 11200: Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions
• 24640: Closed treatment of radial head subluxation in child, nursemaid elbow, with manipulation

Therefore, if you perform one of these procedures and you administer an E/M service within the next ten days that’s related to the procedure, your insurer will likely bundle the payment for the E/M service into the amount you received for the procedure.

If, however, you perform an E/M that’s not related to the procedure, you can use modifier 24 to separate it. For instance, if you performed an I&D for an abscess as in our example above, you probably used the diagnosis for an abscess when you submitted the charge for the surgery. If the patient presents for a repacking of the I&D and the pediatrician also evaluates the child’s acne, you can report the E/M code with modifier 24 linked to the acne code.

Know the Rules for ‘000’ Day Globals

Some services have “000” global days assigned to them, and although you may think that “000” truly means “zero,” that’s not the case. The 000 classification means the procedure adheres to bundling rules only on the date of the service. Most payers will therefore bundle all services that you perform on the surgery date into codes with this 000 global period.

Commonly-performed procedures such as the following carry “000” global days:

• 54150: Circumcision, using clamp or other device with regional dorsal penile or ring block 
• 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
• 69210: Removal impacted cerumen requiring instrumentation, unilateral
• Therefore, if you perform an E/M service that prompts you to perform cerumen removal with instrumentation, the payer will bundle the associated E/M service on that date into the payment for the cerumen removal. If the procedure is not directly related to the visit (e.g., impacted ear wax with an otitis media diagnosis), then bill the E/M code with a 25 modifier to indicate it is a separate service not related to the impaction.

‘X’ Marks the Spot for These Procedures

The majority of procedures that pediatricians perform, such as vaccinations (e.g., 90460, Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered) carry a global period of “XXX.”

An XXX modifier means the service is truly free of global surgical bundling issues, meaning that unless Correct Coding Initiative (CCI) or payer-specific edits bar you from billing the procedure with an E/M code, you should be free to bill an E/M service with the procedure on the date of service.

Commonly-reported pediatric procedures with XXX global periods include the following, among others:

• 96372: Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular 
• 94010: Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement(s), with or without maximal voluntary ventilation 
• 36416: Collection of capillary blood specimen (eg, finger, heel, ear stick)

Therefore, if you perform an E/M service that prompts the pediatrician to decide he should give a medication injection, you should be able to report the E/M code with 96372 without any modifiers appended.