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 [...]