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 [...]