Pediatric Coding Alert

Question: Renee Boston, office manager of Southwest Childrens Center, a five-pediatrician practice in San Antonio, TX, asks whether there is any way to avoid bundling of codes for circumcision and the numbing injection that is sometimes given first.

Circumcision is 54150: Circumcision, using clamp or other device, newborn.

Numbing is CPT 54235 : Injection of corpora cavernosa with pharmacologic agents (e.g. papaverine, phentolamine).

BC/BS denies the 54235 code as being part of the surgical procedure, Boston says, adding that BC/BS is using new bundling software, which is bundling the injection with the circumcision, while other payors are paying for both as separate procedures. Is there any modifier I should be using to increase pay up?

Answer: Actually, Boston is lucky if she is getting reimbursed for both, our experts say. Unless an anesthesiologist is used for anesthesia, insurance carriers are likely to view the numbing as a part of the procedure. The example usually cited to back this up is a surgical one: doctors have to stitch up a patient after an operation, so suturing should be included as part of the surgical procedure, and not a separately reimbursable procedure.

However, both codes do exist. And not all physicians use the numbing part of the procedure. Therefore, you can continue to use both codes, and graciously accept the reimbursement for both that you are getting from some carriers. And modifier 25 wont help you with the bundling software that many third-party payors are now using.