Pediatric Coding Alert

Relief:  Recommendations on 54150, 64450-59 remain unchanged despite increased modifier 59 scrutiny

If you’re having success getting paid for a nerve block with circumcision using modifier 59, rest assured you can keep using this strategy.

The OIG recently reported its findings on modifier 59 use, says Vicky V. O’Neil, CPC, CCS-P, coding and compliance educator in St. Louis, Mo. “The study found that practices are rampantly misusing this tool.” The findings led CMS to encourage carriers to look closely at claims containing modifier 59 (Distinct procedural service)--and caused many pediatric coders to question their policies.

“When billing circumcision (54150, Circumcision, using clamp or other device; newborn) and peripheral (64450, Injection, anesthetic agent; other peripheral nerve or branch), I add modifier 59 to 64450,” says Kimberly Rourke, account specialist at High Desert Valley Pediatrics. Rourke has had success coding claims this way, but she doesn’t want her practice to be flagged for using modifier 59 in this situation.  These explanations will help you use this coding option with confidence.

1. Focus on Finding Coding That Works

Don’t assume that increased scrutiny of modifier 59 claims means you should stop using the tool.

Many of the questions that Pediatric Coding Alert readers have asked regarding the modifier’s use seem to center around concerns of raising a potential audit flag rather than identifying correct coding options that work, says Richard H. Tuck, MD, FAAP, a nationally recognized coding speaker with PrimeCare of Southeastern Ohio.

2. AMA Backs Separate Nerve Block Reporting

In the case of circumcision with nerve block, correct coding allows you to report both the procedure and the anesthesia. CMS policy for 54150 and 64450 does not, however, coincide with CPT guidelines.

The National Correct Coding Initiative edits, version 8.3, “inappropriately bundles the dorsal penile nerve block in the circumcision procedure,” Tuck says. CMS bases the edit, effective Oct. 1, 2002, on CPT’s surgical package, which includes “local infiltration, metacarpal/metatarsal/digital block or topical anesthesia.” But “a penile nerve block is not considered a local infiltration or topical anesthesia,” according to CPT Assistant August 2003, Volume 13, Issue 8. A nerve block is instead a regional anesthesia, which the surgical package doesn’t include.

Also: The AMA Resource Based Relative Value Scale Review Update Committee (RBRVS RUC) and the Centers for Medicare & Medicaid Services established the values for circumcision years before many physicians performed circumcisions with anesthesia, according to Coding for Pediatrics. Thus, insurers should reimburse pediatricians who do this procedure for the extra work, expense and risk involved in performing a dorsal penile nerve block.

Because the AMA permits separately reporting a nerve block with circumcision, you may code both procedures. “Medicare policy does influence coding policy, but should not and does not determine correct coding,” which CPT and the CPT Assistant define, Tuck says.

3. It’s OK to Show 64450 Is Distinct With 59

You may find that “modifier 59 is helpful in overriding the NCCI bundling edit,” Tuck says. The 64450-54150 edit carries a modifier indicator of 1, meaning CMS allows a modifier to override the edit if  circumstances warrant the modifier’s use. Append modifier 59 on 64450 to indicate that the nerve block (64450) is a distinct procedural service from the circumcision (54150).

Modifier 59 will indicate to the carrier that when you performed these services, they were separate and distinct procedures, says Carol Pohlig, BSN, RN, CPC, at the  Hospital of the University of Pennsylvania in Broomall, Pa. Make sure you’re not “trying to unbundle a component service,” she says.

4. Obtain Individual Rules in Writing

Although the circumcision and nerve block edit comes from Medicare, you can expect the policy to affect third- party insurers. “Most private-payer software edit programs are built from the ground up based on the national edits with some additions,” O’Neil says

Whether you should code based on NCCI for all payers is a matter of some contention. “Adopting an all- payer policy in which you code uniformly will give you a solid foundation to support your appeals,” O’Neil says.  

Reality: With insurers’ rules all over the place--for example, one of Pohlig’s payers doesn’t recognize modifier 59--universality doesn’t necessarily work. “If you’re in a small office where you can keep track of various policies, you can code per payer rule,” she says.

Just make sure you obtain coding policies that differ from CMS or NCCI in writing. For instance, some insurers require you to report 54150-64450 with these alternative modifiers:

• modifier 51 (Multiple procedures) on 64450 (nerve block) to indicate a multiple procedure

• modifier 47 (Anesthesia by surgeon) on 54150 to indicate that the same pediatrician who performed the surgical procedure (64450, 64450-51 or 64450-59) also provided the anesthesia.

Tip: If your claim is denied or bundled, consider appealing it, says Victoria S. Jackson, practice management consultant with JCM Inc. in California. A lot of insurance companies are denying these claims, but that doesn’t make it right. If you do appeal, make sure to have all of your information at hand and submit your appeal to the medical review committee, not the claims department.