Pediatric Coding Alert

Question: A 3-year-old child with a history of bad breath was brought to the office. After evaluating the problem, the pediatrician determined that the child had a foreign body in his nose. The physician removed it. Can I code the E/M service separate from the foreign body removal?

North Dakota Subscriber

Answer: Yes, you can claim both services if you have supporting documentation. Here's how:

• Report the E/M service with 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...).

• 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 99213 and link the code to diagnosis 784.99 (Other symptoms involving head and neck) for halitosis.

• Include 30300 (Removal foreign body, intranasal; office type procedure) for the object removal.

Reasoning: Any time you have a separate and distinct E/M service at the time of a procedure, you should be able to report both. Provide separate documentation for both the E/M service and procedure, and append modifier 25 to the associated E/M code. Each service should be linked to a separate supportive diagnosis code whenever possible.

--Answers for You Be the Coder and Reader Questions were reviewed by Richard Tuck, MD, FAAP, pediatrician at PrimeCare of Southeastern Ohio in Zanesville.