Pediatric Coding Alert

CPT Codes 2003 creates a new modifier for the additional work involved in surgical procedures performed on small infants. Medicare and other payers, however, have not indicated whether they will accept the new modifier. New modifier -63 (Procedure performed on infants less than 4 kg) reflects the "increased complexity and physician work commonly associated" with neonates and infants up to a present body weight of 4 kilograms, according to CPT 2003, Appendix AModifiers. Use modifier -63, unless otherwise designated, with procedures/services listed in the 20000-69999 code series only, CPT states. Do not append modifier -63 to E/M, anesthesia, radiology, pathology/ laboratory or medicine codes.

Pediatricians may recall an earlier version of modifier -63. CPT 2001 introduced modifier -60 (Altered surgical field) as an age-specific modifier designed to be used to indicate procedures with increased complexity due to factors such as very low birth weight. "Modifier -63 is the grown-up version of modifier -60," says Richard Tuck, MD, FAAP, medical director of quality care partners for PrimeCare of Southeastern Ohio in Zanesville, and a member of the American Academy of Pediatrics (AAP) national committee on coding and nomenclature (COCN). CPT 2002 eliminated modifier -60.

Extra Work in Code Negates Modifier -63

Numerous CPT codes already encompass additional physician work. Reporting modifier -63 with these procedures is inappropriate because the codes already include the additional work that the modifier represents, states CPT Changes 2003: An Insider's View. Appending modifier -63 in these cases would be redundant and double-billing. To indicate the codes to which you should not append modifier -63, CPT notes, "Do not report modifier -63 in conjunction with XXXXX" after the code descriptor.

For instance, the relative value units for circumcision code 54160 (Circumcision, surgical excision other than clamp, device or dorsal slit; newborn) include the additional physician work necessary to perform the procedure on a newborn. Therefore, you should not append modifier -63 to 54160, and CPT 2003 denotes, "Do not report modifier '-63' in conjunction with 54160" following the code's definition.

Modifier -63 has a long list of exclusions, says John P. Crow, MD, APSA (American Pediatric Surgical Association), Pediatric and Neonatal Coding 2003 presenter at the AMA CPT Symposium in Chicago on Nov. 14. Unfortunately, no complete list of these exclusions exists in CPT. Instead, you have to refer to the individual code to see if it prohibits appending modifier -63. You cannot append modifier -63 to codes

Append Modifier to Invasive Surgical Procedures

The AMA established the modifier "to be appended only to invasive surgical procedures," according to the "Rationale for Modifier '-63' " in CPT Changes 2003. Therefore, pediatric surgeons will use the modifier more frequently than primary-care pediatricians.

For instance, a pediatric surgeon may append modifier -63 to indicate the greater work involved in performing bowel resection on premies who have necrotizing entero-colitis (44140, Colectomy, partial; with anastomosis) or percutaneous gastrostomy (PEG) tube placement on neonates (43246, Upper gastrointestinal endoscopy ... with directed placement of percutaneous gastrostomy tube), Crow says. You may also append modifier -63 to endoscopic procedures, such as 43220 (Esophagoscopy, rigid or flexible; with balloon dilation [less than 30 mm diameter]), that involve small children.

Crow compares the new modifier to modifier -22 (Unusual procedural services). Pediatricians previously used modifier -22 to describe services that required additional work due to the age and size of the patient. Many payers, however, did not recognize modifier -22. Carriers will, hopefully, accept modifier -63 more readily.