Pediatric Coding Alert

Question: When we perform a difficult procedure such as catheterization, can we bill extra? What about using modifier -22?

California Subscriber

 
Answer: When performing certain procedures, such as bladder catheterization, pediatricians may perform more work than internists treating adults. These procedures take extra time and effort when performed on a child, yet CPT doesn't recognize this with a single modifier. Pediatricians should consider modifier -22 (unusual procedural services). Modifier -22 will add to your practice's reimbursement for the code -- practices will have to determine the amount, however. Many pediatric practices double the fee.
 
An aggressive pediatric biller should consider appending modifier -22 to certain codes (examples below) if the documentation supports it. Most payers' computer systems automatically kick out claims with modifier -22, so coders must file manually. Before reimbursement, the payer will want documentation of significant extra effort. Do not assume that a payer will give you more for a service just because of the age or weight of the patient. Avoid appending modifier -22 every time you bill these codes.

Catheterization
 
A relatively simple procedure in an adult, catheterization (53670*, catheterization, urethra; simple) may not be simple in a child. Extra time will be required and extra skill as well. Appending modifier -22 to 53670* may increase the reimbursement, but your documentation must indicate that extra work was performed.
 
Code 53675* (catheterization, urethra; complicated [may include difficult removal of balloon catheter]) for a complicated catheterization has a higher relative value unit than 53670* but may not be as appropriate for the pediatric patient as 53670*-22.
 
Do not use 51010 (aspiration of bladder; with insertion of suprapubic catheter) for a bladder catheterization done to obtain a urine specimen in the office. This would not be done in the office by a pediatrician.

Suturing
 
Laceration repairs that you perform in the office (12001*, 12011*-12013) require extra time and skill in children. An adult would sit still; a 5-year-old might not, making treatment of facial lacerations in particular a time-consuming task. Appending modifier -22 would be appropriate given the proper documentation.
 
Some pediatricians perform more extensive lacerations, and they should bill using the appropriate laceration codes, also with modifier -22, if justified.

Lumbar Puncture
 
Append modifier -22 to a spinal tap (62270*, spinal puncture, lumbar, diagnostic) that is particularly difficult, such as one with multiple sticks. Document both time and difficulty in the record.

Removal of a Foreign Body
 
Foreign-body removal, whether from the nose (30300*, removal foreign body, intranasal; office type procedure), ear (69200, removal foreign body from external auditory canal; without general anesthesia) or skin (10120*, incision and removal of foreign body, subcutaneous tissues; simple), might be so difficult and time-consuming that modifier -22 is justified. For example, it may take extra skill to remove a jellybean from the nose of a frightened and uncomfortable 4-year-old.

Blood Draws
 
Report 36420 (venipuncture, cutdown; under age 1 year) without modifier -22 except in extremely unusual circumstances. Report 36425 (venipuncture, cutdown; age 1 or over) with modifier -22 in an older child who may have great difficulty tolerating the procedure.
 
Report 36410* (venipuncture, child over age 3 years or adult, necessitating physician's skill [separate procedure], for diagnostic or therapeutic purposes. Not to be used for routine venipuncture) when the pediatrician must be involved. For example, in a child older than 3, if the blood vessels are very small and the nurse cannot obtain the blood, the pediatrician might have to perform the procedure. 
 
The most commonly used office venipuncture code -- 36415 (routine venipuncture or finger/heel/ear stick for collection of specimen[s]) -- should have modifier -22 attached if extra work is involved. The pediatrician is not usually involved in blood draws. Do not use modifier -22 on 36415 because modifier -22 is a physician-only modifier, and 36415 does not have to be performed by a pediatrician.
 
Do not bill 36400 (venipuncture, under age 3 years ...) for office blood draws, regardless of the age of the patient. This is an inpatient procedure.

 
-- Answers for You Be the Coder and Reader Questions are contributed by Richard H. Tuck, MD, FAAP, founding chairman and member, AAP coding and reimbursement committee, practicing pediatrician, Zanesville, Ohio; Thomas A. Kent, CMM, CPC, president, Kent Medical Management, Dunkirk, Md.; and Charles Schulte III, MD, FAAP, chairman, AAP coding and reimbursement committee, AAP representative to the CPT advisory committee.