Pediatric Coding Alert

Question: A 10-year-old established patient fell from his bicycle and reported for examination and removal of debris from pavement burns on his forearms. A mid-level provider (MLP) irrigated the wound, and the physician examined the patient’s injuries. After cleaning dirt and gravel out of both forearms, the physician suspected that the patient’s right forearm might contain deeper foreign bodies. The physician ordered a complete, three-view x-ray of the right forearm; the MLP numbed the patient’s forearm, and removed glass shards and debris using pickup forceps and a scalpel. Notes indicate the physician performed an expanded problem-focused history and exam; medical decision-making was of moderate complexity. We performed the x-ray in the physician’s office, and the physician provided the report. How should I code this encounter?

Codify Subscriber

Answer: You should be able to file three codes for this encounter — as long as you use the right modifiers. Add the following codes to your claim:

• Report 10120 (Incision and removal of foreign body, subcutaneous tissues; simple) for the foreign body removal (FBR).

• Report 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity. …) for the E/M service based on the documented expanded problem-focused history and exam with moderate complexity medical decision making. 

• Append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to 99213 to show that the provider performed a separate E/M service in addition to the FBR.

• Report 73110 (Radiologic examination, wrist; complete, minimum of 3 views) for the x-ray.

• Append modifier RT (Right side) to 73110  to show that the x-rays focused on the patient’s right forearm, if the payer requires you use laterality modifiers.

Caveat: The 25 modifier might not be appropriate for some payers; they might prefer you append modifier 57 (Decision for surgery) to 99213 or modifier 59 (Distinct procedural service) to 10120 instead of modifier 25. If you’re unsure about a specific payer’s policy, double-check before making the modifier call.

Also, if you have different diagnosis codes for the visit and the procedure, be sure and append the different diagnoses to the separate line items on your claim. For instance, the visit could be injury to the forearm and the procedure is FB removal from the forearm. Don’t forget to use the E code specific to how the accident happened as a secondary diagnosis code.