Pediatric Coding Alert

Question: A 3-month-old patient presented to our practice for a sick visit. Her mother said she had symptoms of increased irritability and a fever of 101. We billed the office visit with 99213-57 with diagnosis codes 780.60 and 780.92. On a second line item we reported the catheter with 51701 and the diagnosis code 780.60. When the insurer processed the claim they only allowed the catheter procedure and disallowed the office visit entirely. How can I collect for both the procedure and the office visit? Should I have billed the 99213-57 with a different diagnosis?

Answer: Although not a "surgical procedure," inserting a straight catheter is a procedure nonetheless. When a non-surgical procedure is provided with an E/M visit, you should 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 separate and distinct E/M code rather than modifier 57 (Decision for surgery). Therefore, you should have reported 99213-25 with 51701 (Insertion of non-indwelling bladder catheter (eg, straight catheterization for residual urine).