Pediatric Coding Alert

Rule: Scheduled wart removal, I&D = procedure only

You need a new system to determine whether you should code an E/M in addition to a minor procedure. Say 'Goodbye' to Stars "Several years ago it was acceptable to use a 99213 (or other appropriate-level E/M code) as well as codes like 17000, 17003, 30300, 10120, 10060, 11200, etc.," says Dru Heffington, business manager at Cool Springs Internal Medicine and Pediatrics Clinic in Brentwood, Tenn. But that's when a little symbol gave you a clue as to what some minor procedures included.

Starred procedures, designated with an asterisk (*), indicated codes that represented the surgical procedure only. The CPT convention meant that the code did not include any related pre- and postoperative services.

But starred procedures are no longer present in CPT, says Peter Rappo, MD, FAAP, a practicing pediatrician and clinical professor of pediatrics at Harvard Medicine School in Boston. In 2004, the AMA ended this system.

A star, however, was never an automatic green light for also reporting an E/M. Instead, the service still had to qualify as significant and separately identifiable from the procedure (meet the criteria for modifier 25, Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service). That key requirement remains the underlying factor.

Identify a Standalone E/M Note Check if documentation supports a separate E/M service by excluding procedural items. Minor procedures contain some associated work, which CPT refers to as the code's surgical package. This "includes a preprocedure evaluation, the actual procedure and postprocedure care up to a set number of days," says Jeffrey F. Linzer Sr., MD, FAAP, FACEP, associate medical director for compliance and business affairs at EPG in Egleston, Ga.

Don't overlook: To also bill an E/M code, the service note must stand on its own. You have to have a history, examination and/or medical decision-making that supports the office visit level you are reporting. This cannot overlap with the procedure note. When you do have two separate notes--one for the service and one for the procedure--and the service note is codeable by itself, you should report the E/M service appended with modifier 25.

Want some solid examples of modifier 25 in action? Let's look at what a significant, separate service means in addition to some of the procedures Heffington listed above. Code 25-Service When a Spot Is Evaluated Expect to code for a service in addition to wart removal when you first have to diagnose the problem. Compare these two examples:

Example 1: At a preventive medicine service, a mother doesn't have time for you to remove a wart from her child's hand, so she schedules an appointment for the next week. During the second visit, you [...]