A 3-year-old male presented to the pediatrician’s office after the patient’s mother discovered that the boy had inserted a jelly bean into his nose. The mother, when trying to remove the jelly bean, ended up pushing the bean further into the patient’s nose to the point that it is no longer visible. Upon presentation, the patient was extremely agitated and anxious, and was experiencing pain and swelling in the left nasal sinus. The pediatrician determined that due to the patient’s emotional state and the depth of the jelly bean, the patient would have to be anesthetized in order to remove it. The pediatrician admitted the patient into the hospital and performed the removal of the foreign body under general anesthesia. At one point, a lateral rhinotomy was considered but ruled out, as the physician was finally able to grasp the foreign body. How should the pediatrician code for this service?
Explanation
Answer: A - The pediatrician should code for this service with 99214, for the office visit evaluation and management service. This code should be appended with modifier -57 to indicate that this procedure resulted in a decision for surgery, which was performed later that day. Code 30310, for the removal of the foreign body under general anesthesia, also needs to be included to bill for the removal of the jelly bean from the nose. Code 30320 is incorrect because it includes the removal of a foreign body by lateral rhinotomy. Although the pediatrician considered the lateral rhinotomy, it was not performed, and therefore cannot be billed on the claim
