Pediatric Coding Alert

Hint: Modifier -24 or -25 depends on circumcision, service date
 
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). -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.

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:
  99238-25 - significant, separate discharge 

V30.0 - single liveborn
  54150-47 - circumcision with anesthesia by surgeon

V50.2 - Routine or ritual circumcision
   64450-51 - dorsal penile nerve block as multiple procedure 

V50.2 - circumcision. -24 Indicates Unrelated, Post-Op Service In contrast, modifier [...]