Pediatric Coding Alert

Private-payer bundling of newborn circumcisions with E/M visits has caused decreased reimbursements for many pediatricians. But recently, pediatricians in Indiana persuaded at least one insurance company, Anthem, to remove this arbitrary edit, which is not in CPT Codes or CCI.
 
If performed in the hospital, the circumcision (54150, circumcision, using clamp or other device; newborn, or 54160, circumcision, surgical excision other than clamp, device or dorsal slit; newborn) is bundled by some payers with subsequent hospital care codes (99231-99233) or discharge day codes (99238-99239). If performed in the office, the same payers bundle circumcision with the office visit code (99201-99215).
 
This unofficial bundling makes it impossible for pediatricians to be paid for both services they perform. The reason for the E/M is completely different from the reason for the surgery. All newborns must be examined for possible problems; some are circumcised as well. Modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) is appended to the E/M to reflect this distinction.
 
We fought Anthem for three years over the circumcision codes, says Anne Cutler, practice administrator for Bristol Street Pediatric Associates in Elkhart, Ind. They bundled the E/M into the circumcision because they said circumcision was a surgery, even though its not a starred procedure. They wouldnt pay for any other service the same day of a surgery.
 
Cutler argued that Anthem was practicing sex discrimination by not covering the subsequent hospital visit when done the same day as the circumcision. They would pay for a hospital visit for a girl baby, Cutler says, but not for a boy baby who was getting circumcised.
 
What ultimately worked was that Cutlers group and many other providers in the area refused to sign contracts with Anthem, a major managed care company for large employers in northern Indiana. It was not an official boycott, but an assortment of problems for Anthem finally led the company to reconsider its stance.
 
The media covered the pediatricians complaints and contract issues. Employers called pediatricians to find out why they werent signing and complained to Anthem. Finally, Cutler wrote the Indiana State Medical Association and the insurance commissioner to complain. Within three days, Anthem said it would pay for the circumcision and the E/M on the same day. It wont, however, make the payment retroactive.