Pediatric Coding Alert

Lean on these sources for ammunition--if your coding passes muster

When you're unsure whether you should resubmit a claim for an E/M code with circumcision or appeal the service nonpayment, this three-point checklist will tell you how to proceed.

If your coding entry turns up any red flags, refile the claim. Otherwise, include the following supporting documentation with your appeal.

Verify 54150-54160 Claim Contains 3 Items

Your same-day E/M service and circumcision coding scores 100 if:

• You attached the appropriate modifier to the correct code. Append the E/M code (such as 99433, Subsequent hospital care, for the evaluation and management of a normal newborn, per day, or 99238-99239, Hospital discharge day management ...) with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to indicate that the pediatrician performed a significant and separate E/M service on the same day as the circumcision (such as CPT 54150 , Circumcision, using clamp or other device; newborn).

Warning: Apply modifier 25 to same-day E/M service/circumcision claims only. For 54150 claims dated before Jan. 1, 2005, and on all 54160 (Circumcision,
surgical excision other than clamp, device or dorsal slit; newborn) submissions in which the pediatrician performed the service on a day after the circumcision,  you should instead append the E/M code with modifier  24 (Unrelated evaluation and management service by   the same physician during a postoperative period).
     
Modifier 24 indicates the service is unrelated to the circumcision's 10-day global period, which was the defined global period for 54150 prior to 2005 and  54160's current global-day designation. If you didn't use modifier 24, insurers could include the E/M service in  the circumcision's surgical package.

• Documentation includes a separate note for the E/M service and the circumcision. The pediatrician should have recorded the E/M-related history, examination and medical decision-making in a separate entry from the circumcision. Tip: When submitting an appeal, highlight the chart note paragraph that shows the E/M as a significant and separate service from the circumcision.

• You used specific diagnoses to reflect the separate service and procedure. For instance: When coding a same-day normal hospital visit and circumcision, you should link 99433 to V30.xx (Single liveborn) and 54150 to V50.2 (Routine or ritual circumcision).

Argue Denials With Copies of These Bullets

You submit a flawless claim, but the insurer refuses E/M payment. Include with your appeal letter the corresponding denial-combating supporting documentation.