Pediatric Coding Alert

Managed cares latest curve ball to pediatricians is a refusal to pay for newborn circumcisions in addition to a hospital visit. Typically, the baby is circumcised the day after birth and sent home the next day. The pediatrician uses 99431 (history and examination of the normal newborn infant, initiation of diagnostic and treatment programs and preparation of hospital records) for the first visit, 99433 (subsequent hospital care, for the evaluation and management of a normal newborn, per day) for the second day, and CPT 99238 (hospital discharge day management, 30 minutes or less) for the discharge day. On the second day, the pediatrician would also use 54150 (circumcision, using clamp or other device; newborn) on the second day.

The problem is that insurance companies are starting to say the pediatrician cant use both an E/M code and a circumcision code on the same day. Usually theyll just pay for the circumcision, and they wont pay for the hospital visit, says Victoria S. Jackson, administrator and CEO of Southern Orange County Pediatric Associates, a seven-pediatrician, six-nurse practitioner practice in Lake Forest, CA. Were at their mercy, she says. But there are some ways to deal with this problem.

1. In-office circumcisions. For companies that have identified themselves as paying for only the circumcision, we bring those patients into our office for a circumcision, says Jackson. However, if the company wouldnt pay for a hospital visit, it probably wont pay you for an office visit, or for a circumcision tray (if you use disposable equipment), or for your labor involved in autoclaving, if you do that, she adds. But its still a better deal to do circumcisions in the office and lose the office-visit fee, Jackson opines, especially if you schedule wisely. If you have the time to do three to four circumcisions in an hour in the office, thats the way to do it, she says.

Tip: If the reason for the visit is only a circumcision, then it is incorrect to bill for an office-visit as well. However, if the reason for the office visit is to check the babys weight, for example, then you could.

2. Appeal. Tanya Mathews, accounts manager for Newborn Services, Inc., a five-neonatologist practice in Columbus, OH, says you have to appeal every denial. I have to a fight for every one of them, says Mathews, referring to the circumcisions done by the neonatologists on babies who are about to be discharged from the NICU. Eventually we get paid [for the visit and procedure] on the appeal. She does still have several Cigna denials that are two years old, she reports. But, shes not giving up.

Tips: Its not always necessary to send a lot of documentation for your appeals. Simplicity can work best. Ive written appeals saying that the only medical reason we had for doing a circumcision is that the baby is a boy, Mathews says. It works."

Mathews E/M codes are different from the ones used by the primary care pediatricians referred to in the first paragraph of this article. She would use 99295 for the first day, which would be far in advance of the circumcision; and 99296, 99297, and 99298 for subsequent days, with 99298 the one most likely to be used during the last days. For the discharge day, she would use 99283 for 30 minutes or less, or 99239 for a discharge taking more than 30 minutes.

3. Refuse to do circumcisions. Sometimes drastic actions call for drastic responses. The situation for Mathews is not drastic yet, because she is winning her appeals. But it is serious, because insurance companies are not only refusing to pay for the day the circumcision is done, but are refusing to pay for three days after as well. They say its surgery, and that post-op days are included in the circumcision code, she relates. We never signed a contract saying if we do a circumcision, we wont get paid for the rest of the care provided that day, she says. So were telling parents covered by one company that we wont do [their] circumcisions. Mathews points out that parents dont even know about the problem.

4. Utilize referrals. Its not that insurance companies dont think babies need to be seen on subsequent hospital days. After all, they pay for female babies to be examined. And they will pay for a circumcision and a hospital visit on the same day, as long as two different physicians are involved. This is even the case in NICUs. If a primary care pediatrician, for example, goes into a NICU to do a circumcision, the neonatologist will be paid for the hospital day, and the pediatrician will be paid for the circumcision. It makes you wonder if they would pay for a circumcision if a different pediatrician from the primary care pediatrician performed the surgery, says Jackson, only half-joking. What about a referral to a urologist? This would probably cost the insurance company at least three times as much as a circumcision done by a pediatrician. The insurance company might not even process the referral because its something a pediatrician is able to do, says Jackson. But she concedes its worth a try.

5. Timing. If a company is going to refuse to pay you for the days following a circumcision, saying these days are part of a post-op period and therefore covered by 54150, you need to do the circumcisions as close to discharge as possible, so you lose as few days as possible, says Mathews. For her practice, this means doing them on the day of discharge. They used to do circumcisions a few days before discharge, so they could check it, she explains. But we dont have that luxury any more. Now we do the circumcision the last day. That means Mathews is losing the discharge day, but no other days, in terms of billing. Circumcision is surgery, and it does make sense for there to be a post-op period, during which the physician doesnt charge for checking the patient. But the pediatrician examines the child on each hospital day regardless of whether a circumcision has been done.

So what companies are doing to Mathewsrefusing to pay for three days subsequent to the circumcision, as well as the day of the circumcisionreally doesnt make sense. Theyre paying us on girls for all the days, Mathews notes.

6. Modifier -25. K. C. Cougle, accounts administrator for Childrens Health Care, a six-pediatrician practice in Allentown, PA, has no problems at all getting paid for a hospital visit and a circumcision on the same day. We use modifier -25, and we have no problems whatsoever, she says. The modifier goes on the hospital visit (99433). Modifier -25 is for a significant, separately identifiable evaluation and management service by the same physician on the same day of a procedure or other service. The only companies that dont pay it are the ones which do not cover circumcisions at all, says Cougle.

7. Type of service. Its important to put the circumcision code in the surgery column, and not the medical column, on the claim, says Cougle. Its surgery, and it should be called surgery, she says. If you call it medical, and youre also filing 99433, you will have a problem, she notes. Cougle recommends taking up the problem with the provider relations representative at the carrier. We have no problems whatsoever getting paid, she reiterates.