Pediatric Coding Alert

Watch for this key action before looking beyond E/M codes.

A mother brings her daughter to your office and asks your staff to remove a tick from behind the child's knee. If you're unsure when to consider the removal part of a typical office service versus foreign body removal, let these scenarios and our experts' recommendations help guide your choices.

Uncomplicated Removal Is E/M

The tick is on the back of the child's left knee, but hasn't buried itself. The pediatrician grasps and removes the tick with forceps. The removal is uncomplicated and doesn't require any digging.

Code it: "If the provider or staff member simply grasped the tick and removed it without any incision, then I would recommend reporting only an E/M code," says JoAnne M. Wolf, RHIT, CPC, coding manager for Children's Physician Network in Minneapolis, Minn. Such a simple removal supports the lowest-level office visit E/M codes: 99201 (Office or other outpatient visit for the evaluation and management of a new patient ) or 99211 (Office or other outpatient visit for the evaluation and management of an established patient ).

You might be able to justify reporting 99212 based on time if the visit includes significant discussion of parental concerns, says Richard L. Tuck, MD, FAAP, a pediatrician at PrimeCare of Southeastern Ohio in Zanesville. You would still report 99201 for a new patient unless you pass 10 minutes of face-to-face time with the patient and/or family.

More Time Could Merit +99354

The tick's head is buried, but the remainder is free. The parents tried unsuccessfully to remove the tick before bringing the child to your office. You spend 35 minutes attempting to remove the tick with forceps. You remove the tick, but must dig around with forceps in order to do so.

Code it: Once again, our experts recommend reporting an E/M code but nothing related to foreign body removal since the physician didn't make an incision. You can report a higher level code, however, because of the additional time and effort. Code 99212 should be adequate.

Time factor: You could potentially report prolonged care in addition to the E/M service, Wolf says. If so, submit +99354 (Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service; first hour [List separately in addition to code for office or other outpatient evaluation and management service]). Remember that you must document at least 30 minutes with the patient before reporting +99354 for prolonged services.

Incision Sets Up Foreign Body Removal

The tick is more than halfway buried. You attempt to remove the tick with forceps, but cannot. The provider applies topical anesthetic and uses a #11 blade to make an incision to remove the tick. In most cases, you won't need to perform closure.

Code it: You can now report foreign body removal (FBR) because you made an incision in order to remove the tick. Report 10120 (Incision and removal of foreign body, subcutaneous tissues; simple) in addition to an E/M code, such as 99212. Append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician of the same day of the procedure or other service) to the E/M code.

"You do not need to have stitches in order to report 10120," Wolf says. "Code 10120 does include simple closure, however, so you won't report that separately."