Pediatric Coding Alert

Is loss of consciousness required for a concussion? Find out here.

As your patients head back to school and leave behind summer activities like tree climbing and swimming, you might think your practice will be less busy. But when summer ends, autumn issues will begin to impact your patient base, and you’ll see patients present with cool weather problems. Read on to find out how to address these common fall coding issues.

Connect With Codes for Hay Fever Shots

Question 1: A patient who requires immunotherapy due to hay fever brings in serum for his biweekly allergy injection. Which CPT and ICD-9 codes should I use for giving one injection and monitoring the patient? Do I report an E/M visit for the nurse’s service?

Answer 1: Because your office provides the injection administration only, you should report 95115 (Professional services for allergen immunotherapy not including provision of allergenic extracts; single injection). This code includes providing the shot and monitoring the patient for any adverse reactions.

Don’t separately report an office visit unless the nurse provides a significant, separately identifiable service. You can code a nurse visit (99211, Office or other outpatient visit for the evaluation and management of an established patient ...) in situations such as the following: When a child presents for his shot, he has a cough (786.2). The nurse evaluates him to make sure he is healthy enough to receive the shot and documents his temperature and respiratory rate. In this case, report 95115 and 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 99211 to indicate that the office visit is a documented, significant, separately identifiable service from the injection.

Be Careful When Coding Head Injuries

Question 2: Our office manager will only let us report a concussion diagnosis code if the patient loses consciousness, but our pediatricians disagree, leaving the coders caught in the middle. We see more concussions in the fall with the start of football and soccer, so we’re trying to get this ironed out. Which is accurate?

Answer 2: Your pediatricians are correct. A patient does not have to be unconscious to code a concussion—the diagnosis should be made on the patient’s symptoms and not on whether or not he is awake. However, there is more to coding head injuries than just noting consciousness.

If the patient has a contusion of the head, you should use 920 (Contusion of face, scalp, and neck except eye[s]), but remember that a contusion, by definition, includes a bruising injury that does not break the skin. You should check for exclusions in your ICD-9 book. The exclusion note for 920 refers to various other codes for more significant injuries that go beyond a basic bump on the head.

When the provider doesn’t document any further detail than “head injury,” you should use 959.01 (Other and unspecified injury to head). This code also has a list of exclusions similar to 920. Whenever possible, you should use a more specific diagnosis such as head contusion (920).

Significant injuries: You should report codes from the 850-854 series, including 854.01 (Intracranial injury of other and unspecified nature; without mention of open intracranial wound; with no loss of consciousness), for other specific and serious injuries involving the head, such as concussions, cerebral contusions. This series represents very serious injuries resulting from high-energy impacts to the head. Specifically, the 854 set includes cavernous sinus and intracranial injury.

If the patient had a brain injury more than a year ago, you should look to a late effects code. Using a late effects code creates the causality relationship between a prior injury and the current condition your provider is treating.A possible example is 907.0 (Late effect of intracranial injury without mention of skull fracture). In addition, you want to code as primary the actual residual condition for which the pediatrician is seeing the patient, such as mild memory disturbance (310.8) or chronic post-traumatic headache (339.22).

What it is: A late effect is the residual effect (condition produced) after the acute phase of an illness or injury has ended. There is no time limit on when you can use a late effect code. The residual may be apparent early, such as in cerebral contusion (851.4) cases, or it may occur months or years later, such as that due to a previous injury. In pediatric patients, this may be residual dizziness (780.4) or diplopia, also known as double vision (368.2) following
a concussion.

Coding late effects generally requires two codes sequenced in the following order: first, the condition or nature of the late effect; and second, the late effect code. For instance, the condition code could be confusion (293.1, Confusion, subacute), followed by 907.0 (Late effect of intracranial injury without mention of skull fracture).

Don’t Automatically Append Modifier 25 With Nursemaids Elbow Visit

Question 3: Our pediatrician treated a 3-year-old patient for nursemaid’s elbow after he fell on the street while trick-or-treating during Halloween. What procedure code represents this procedure, and which ICD-9 code should I report on this claim?

Answer 3: You’ll report the procedure with 24640 (Closed treatment of radial head subluxation in child, nursemaid elbow, with manipulation). On the claim, be sure to link 832.2 (Nursemaid’s elbow) to 24640 to represent the patient’s affliction.

You’ll typically be able to report a separate evaluation and management code along with 24640, assuming that the pediatrician documents an appropriate history, examination of the patient, and medical decision-making that he performed before treating the injury.

If the procedural notes justify a separate E/M along with 24640, be sure to attach 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 the E/M code. Optimal documentation would be to provide separate evaluation/management and procedure notes. Distinct diagnoses linked to each CPT code, although not absolutely necessary, would be best.