Pediatric Coding Alert

54150 now contains 0 global days, and E/M code inclusion is sexually biased

You can fight same-day E/M service denials on circumcision claims by emphasizing the visit as a significant and separate neonatal care standard.

Real-world coding: When a pediatrician performs a circumcision (such as CPT 54150 , Circumcision, using clamp or other device; newborn) and provides a subsequent hospital visit (99433, Subsequent hospital care, for the evaluation and management of a normal newborn, per day) or discharge service (99238-99239, Hospital discharge day management ...), many carriers reject the visit code, says Pat Johnson, office manager at Neonatal Associates in Louisville, Ky. Insurers bundle the E/M code into the procedure due to pre- or postoperative days or procedure-E/M inclusions. Clear the E/M code payment hurdle with these tactics.

1. Attach Modifier 25 to the E/M Service Code

If you submitted the claim without a modifier, try appending the E/M code with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). Modifier 25 tells the insurer that the pediatrician performed a significant and separate E/M service on the same day as the procedure--the circumcision, says Victoria S. Jackson, administrator at Southern Orange County Pediatric Association in Lake Forest, Calif.

Example: A pediatrician performs a circumcision using a clamp and later on the same day discharges the infant. You should report the circumcision (54150) and attach modifier 25 to the discharge code (99238-99239).

Exception: If you're getting paid for the E/M service without using a modifier, maintain your method. "I don't have to use modifier 25," says Richard H. Tuck, MD, FAAP, a pediatrician at PrimeCare of Southeastern Ohio.

On appeals for 99238-99239 services appended with modifier 25, stress that the circumcision does not include a separate, significant E/M service. "Hospital policy requires the pediatrician to examine every infant prior to discharge to make sure he or she is well enough to go home," Jackson says.

Point out that the E/M service is medically necessary whether the baby has a circumcision or not. "This is the accepted standard of care for neonates in the hospital," Tuck says.

Emphasize that 9923x is distinct from and totally unrelated to 54150. "The discharge service includes an unrelated history, exam and medical decision-making as well as counseling of the parents irrespective to the circumcision," says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CHBME, president of CRN Healthcare Solutions in Tinton Falls, N.J.

Warning: Don't use modifier 59 (Distinct procedural service) on the circumcision code instead of modifier 25 on the E/M code. "You should reserve modifier 59 for a circumstance in which no other modifier appropriately describes the codes' relationship," Cobuzzi says. Because modifier 25 correctly indicates the E/M service and circumcision's relationship, you should instead attach modifier 25 to the E/M code.

2. Cite Postoperative Period Change

Proper modifier use may not halt denials from insurers that include the visit in the circumcision's surgical package. "We appeal all of these rejections stating that there are no pre- or post-op days for a circumcision," Johnson says. Code 54150's zero-day global period may, however, surprise insurers.

Why: Prior to 2005, circumcision code 54150 contained 10 global days. "The 2005 National Physician Fee Schedule erroneously misprinted 54150 as having 'XXX' global days," says Diane Milstead, health insurance specialist at CMS. Correcting amendment CMS1429F2 assigns zero global days to the code.

"When a circumcision is billed in conjunction with an E/M code, the zero-day designation still promotes ongoing confusion and denials by payers," Tuck says. That's why the American Academy of Pediatrics Committee on Coding and Nomenclature has repeatedly recommended that CMS make 54150 an XXX-global-day procedure, which means the global concept does not apply.

In contrast, a zero-global-day code includes related preoperative and postoperative relative values on the day of the procedure, according to the National Physician Fee Schedule Relative Value File. "Evaluation and management services on the same day of the procedure [are] generally not payable," CMS says.

Key: Code 54150 includes same-day related E/M services. You are, however, coding a significant and separate E/M service with different ICD-9 codes, as CPT allows.

Use this same argument to combat E/M code denials with 54160 (Circumcision, surgical excision other than clamp, device or dorsal slit; newborn), which still contains 10 global days.
 
3. Inform Payer of Illogical, Sex-Biased Bundle

If the insurer then argues the reverse--that the visit includes a circumcision--wield the sex-discrimination card. "Point out to the representative or in your appeal letter that the female newborn's E/M service (99433, 99238-99239) does not include a circumcision (54150)," Jackson says. Making 54150 part of E/M codes for male patients only is sexually biased  because the policy imposes different sex-based inclusions, she reasons.

Also: Explain that the above interpretation should cause the payer to reject the circumcision, not the E/M service. "Claiming that a visit includes a circumcision and then bundling the modified 99433 or 9923x code into 54150 is illogical," Jackson says. This may convince a payer to change its policy.

4. Obtain Contract Copy

You can use an insurer's contract to battle its circumcision/E/M service edit. "If the contract covers circumcision and newborn care, ask the insurer where the policy makes one service a component of the other," Jackson says.

5. Perform Circ in Office--or Not at All

If the above tactics prove fruitless, consider revising your circumcision offerings. "I perform circumcisions in the office only," says Diana McLaughlin, MD, FAAP, founding pediatrician of Kids' Medical Care in Naples, Fla. The protocol reduces the risk of a newborn having adverse reactions to the procedure due to jaundice that was not yet found, she says.

Most pediatricians perform a separate and significant E/M service (such as 99213-25, Office or other outpatient visit for the evaluation and management of an established patient ...) prior to performing an in-office circumcision. Therefore, you may experience the same denial issues a same-day hospital E/M and procedure code can involve.

Good news: The policy revision could end your E/M service with circumcision bundles. "When patients come to my office for a circumcision, I receive payment for both the same-day service and the procedure," says Charles A. Scott, MD, FAAP, pediatrician at Medford Pediatric & Adolescent Medicine PA in New Jersey. "Insurers sometimes don't pay much for the 54150--about a quarter of the charges."

Alternative: Don't perform circumcisions at all. "Instead, you could refer the parent to a urologist," Jackson says.