Pediatric Coding Alert

Question: The December 2002 Pediatric Coding Alert states that we should fight all denials for penile nerve blocks that are billed with a circumcision. It also states that this is not a bundled procedure in the CCI edits. Which CCI edits are you using? Medicare CCI or National? National states that 64450 is a component of 54150. We are trying to fight these but are still getting nowhere. What should we do?

Illinois Subscriber

Answer: On further review of the edits, the final-quarter 2002 National Correct Coding Initiative (NCCI) version 8.3 bundled the dorsal penile nerve block or ring block (64450*, Injection, anesthetic agent; other peripheral nerve or branch) into the circumcision codes (54150-54161), which include 54150 (Circumcision, using clamp or other device; newborn) and 54160 (Circumcision, surgical excision other than clamp, device or dorsal slit; newborn). Medicare considers the nerve block integral to the circumcision and does not allow separate payment for it.

Although private payers are not required to observe the edits, many do, either in whole or in part. You may still bill commercial carriers and Medicaid for both procedures. Include CPT's definition of a surgical package, which does not include nerve blocks. Point out that an operation includes local infiltration, metacarpal/ metatarsal/digital block or topical anesthesia, but not nerve blocks.

In addition, you should inform the payer that the nerve block is a regional, not a local anesthetic. The AMA special society relative value scale update committee established the values for circumcision years before many physicians performed circumcisions with anesthesia, according to Coding for Pediatrics 2003, the American Academy of Pediatrics'annual publication. Thus, insurers should reimburse pediatricians who do this procedure for the extra work, expense and risk involved in performing a dorsal penile nerve block.

The national edits are the same thing as Medicare edits. CMS contracts with AdminaStar Federal, a Medicare carrier in Indiana, to propose and maintain a system of coding edits for Medicare Part B carriers. The NCCI, the only authorized distributor, publishes the edits quarterly.

Some discrepancy occurs as to whether publications and companies use the abbreviation "NCCI" or "CCI." But the abbreviations refer to the same edits. Some entities, such as the CMS Web site and the AMA, refer to the edits as the Correct Coding Initiative (CCI) edits. The CMS policy narrative that AdminaStar releases with the National Correct Coding Policy Manual calls them the National Correct Coding Initiative (NCCI) edits.

CMS developed the NCCI to promote national correct coding methods and to control improper coding that leads to inappropriate payment in Part B claims, according to the narrative. The agency bases the policies on coding conventions defined in the CPT manual, national and local policies and edits, national societies'coding guidelines, standard medical and surgical practice analysis, and review of current coding practice. For more on the edits, visit the CMS Web site at www.cms.hhs.gov/medlearn/ncci.asp.

Answers to You Be the Coder and Reader Questions provided by Richard H. Tuck, MD, FAAP, American Academy of Pediatrics'representative to the AMA's resource-based relative value scale review update committee.