Pediatric Coding Alert
Test Your 'Unrelated' Versus 'Separate' E/M Modifier Skills
Hint: Modifier -24 or -25 depends on circumcision, service date -25 Identifies Separate, Same-Day E/M Modifier -25 typically describes the relationship between a same-day service and a circumcision. "The -25 tells the insurer that the pediatrician performed a significant, separately identifiable service from the circumcision," says Imelda Y. Lee, RHIA, CTR, pediatric coding and department of pediatrics for the University of Texas Health Science Center in San Antonio. -24 Indicates Unrelated, Post-Op Service In contrast, modifier -24 may apply when you bill an E/M service on a date following the circumcision. Before you use modifier -24, make sure the encounter meets two criteria: Post-Op Modifier Omission Causes E/M Denial Don't forget to use modifier -24 on service claims during 54150 or 54160's global period. Otherwise, the payer may bundle the E/M service into the circumcision's global period. "Modifier -24 tells the insurer that the service has nothing to do with the circumcision," says Sharon Newman, CPC, coding education and documentation coordinator at Children's Specialty Group in Norfolk, Va. Another example: You treat a child for otitis media (OM) one week after you performed a laceration repair on the patient. Odd Written Rules Deserve Conformity If an insurer tells you to use modifier -24 instead of modifier -25 with a circumcision and E/M, do so. "But don't take a 'verbal' request that the company may not honor in the future in the event the insurer challenges your coding," Scott says.
To choose what modifier to use on a infant boy's service code claim, you should look at whether the circumcision occurs before or on the E/M day.
Even though modifiers -24 and -25 both go on the E/M code, their similarities end there. Modifier -24 (Unrelated evaluation and management service by the same physician during a postoperative period) tells an insurer that the E/M service is unrelated to the original procedure's global period.
In contrast, modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) identifies a service that is significant and separate from the procedure on the same day of the procedure. Examine how each modifier applies in a common pediatric scenario.
Case study: When a baby boy has a circumcision at the hospital on the same day as either a discharge or a subsequent hospital visit charge, should I use modifier -24 or -25? asks Jamie Kurrasch, CPC, pediatric coding specialist at Primary Care Partners in Grand Junction, Co. "I have different insurances that are requesting different modifiers."
To get CPT's answer, focus on when the circumcision (such as 54150, Circumcision, using clamp or other device; newborn) occurs in relationship to the E/M service (for instance 99238, Hospital discharge day management; 30 minutes or less; or 99433, Subsequent hospital care, for the evaluation and management of a normal newborn, per day).
Key: You use modifier -25 to designate a significant and separate E/M on the same day of the procedure. CPT clearly makes the distinction that modifier -25 is for a service that the same physician performs "on the same day of the procedure or other service."
So if you perform a separate history, evaluation and medical decision-making on the same day that you perform a circumcision, you report the service appended with modifier -25.
Example: You circumcise a newborn and later discharge him from the hospital. You would append modifier -25 to the discharge code to designate the discharge as a significant, separately identifiable service from the circumcision-related E/M. The claim could read:
V30.0 - single liveborn
V50.2 - Routine or ritual circumcision
V50.2 - circumcision.
1. You're in a global period. CPT designates modifier -24 for an unrelated E/M service "by the same physician during the postoperative period." An E/M service on the same-day as a circumcision "isn't a post-op period," says Charles A. Scott, MD, FAAP, pediatrician at Medford Pediatric & Adolescent Medicine PA in Medford, N.J. The postoperative period starts the day after a circumcision.
During the circumcision's global period, all related E/M services are part of the surgery's postoperative care. Both 54150 and 54160 (Circumcision, surgical excision other than clamp, device or dorsal slit; newborn) contain 10 global days, Lee says. For follow-up visits during this time, you would not use an E/M code.
2. If the service is unrelated to the circumcision, you should assign the appropriate E/M code. "When a pediatrician performs the E/M for something completely different from the global period procedure, modifier -24 would be appropriate," says Jacqueline F. Clouse, RHIT, CPC, CCP, coding educator for the Tennessee Chapter of the American Academy of Pediatrics.
Right way: Two days after you perform a hospital circumcision on a newborn, you see the patient in the office for jaundice. For the office encounter, you could use 99213-24 (Office or other outpatient visit for the evaluation and management of an established patient ...) with 774.6 (Hyperbilirubinemia).
Why: You would use modifier -24, because:
1. the office visit occurs within the circumcision's postoperative period
2. the E/M is for jaundice and is thus unrelated to the post-op period.
The OM E/M is unrelated to the laceration repair's postoperative period (such as 12001, Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk, and/or extremities [including hands and feet]; 2.5 cm or less - 10 global days - with 880.03, Open wound of upper arm).
Therefore, you would append modifier -24 to the office visit code (9921x-24 linked to the OM diagnosis, such as 382.00, Acute suppurative otitis media without spontaneous rupture of ear drum).
Better way: Get the instruction in writing. "Have the representative e-mail or fax you the suggested method," Clouse says. "If the insurer won't do that, tell the person that you will write a summary of your discussion and send it to him to make any changes."
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