Pediatric Coding Alert

One coder shares her 64450 success story

If you're not billing CPT 54150 and 64450 for circumcisions, you're losing big bucks for the nerve block each time.

Because the National Correct Coding Initiative (NCCI) version 8.3 bundled 54150 (Circumcision, using clamp or other device; newborn) into 64450* (Injection, anesthetic agent; other peripheral nerve or branch), many pediatricians and coders stopped reporting the dorsal penile nerve block for fear of unbundling violations, says Joanne Sherrill-Drummer, emergency associate coder at Community Hospital of Monterey in Monterey, Calif.

But Sherrill-Drummer says an answer to a reader question in the March 2003 Pediatric Coding Alert helped her pediatricians see that they could bill 64450 and 54150. Because CMS based the circumcision edit on Medicare's budget instead of correct coding guidelines, you should still bill private payers and Medicaid for 64450, she says.

The advice prompted several coders to again try reporting 64450 (dorsal penile nerve block or ring block) with 54150. "I showed my pediatricians Dr. Tuck's explanation that CPT includes digital blocks in its surgical package, but not nerve blocks," Sherrill-Drummer says. After that, her physicians had no more concerns about reporting 54150.

"Our pediatricians started charging for 54150," says Kathy Willborn, practice manager at Cook Children's Physicians Network in Hurst, Texas. But most of the time, payers still reject the nerve block, she says. So, she has to write off the charge.

Don't give up, Sherrill-Drummer says. If you follow these four tips recommended by coding experts, you'll stand a better chance of improving your nerve block reimbursement (64450, 1.77 facility relative value units):

If an insurer denies 64450 as included in the surgical package, inform them that CPT does not include nerve blocks in its surgical package. Send the insurer a copy of CPT's surgical package definition that includes "local infiltration, metacarpal/metatarsal/digital block or topical anesthesia" and excludes nerve blocks.

Also, be prepared to explain to the insurer that a nerve block and a digital block are not the same thing. A nerve block is similar to an epidural, in which the anesthetic numbs the whole nerve, Sherrill-Drummer says. In contrast, a digital block affects the digit only.

Because pediatricians perform the digital block in addition to a circumcision, Sherrill-Drummer appends modifier -51 (Multiple procedures) to 64450 (nerve block) to indicate a multiple procedure. "We've had no denials since the beginning of the year," she says.

Other coders report success using modifier -59 (Distinct procedural service) on 64450 to indicate that the nerve block (64450) is a distinct procedural service from the circumcision (54150).

You may also need to add modifier -47 (Anesthesia by surgeon) to indicate that the same pediatrician who performed the surgical procedure (the circumcision) also provided the anesthesia. "I use modifier -47 on 54150 for Champus," Sherrill-Drummer says. On claims with 54150-47, 64450-51, Champus reimburses more quickly than any of Sherrill-Drummer's other payers.

If these modifiers don't get 54150 paid, add a coverage clause when your contracts come up for renewal, Willborn says. Regardless of payment, make sure you code the procedure for accurate coding, she adds.