Pediatric Coding Alert

Question: Our pediatrician just performed services for a newborn. On the first day, she performed a frenotomy along with the initial care of the neonate. She performed subsequent care on the second day, then circumcised the child and discharged on the third day. We submitted 99460-25and 41115 for day one, 99462 for day two, and 99238-25 and 54150 for day three, but our payer denied the claim. What did we do wrong?

Utah Subscriber

Answer: There seems to be two problems with your claim. For the first day, in addition to 99460 (Initial hospital or birthing center care, per day, for evaluation and management of normal newborn infant) with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service), you billed 41115 (Excision of lingual frenum (frenectomy)).

By adding the 25 modifier to both visit codes, you are indicating that the visits are not related to the procedures performed during the time of the services. And if you make certain the diagnosis codes are correctly applied to the different services, this will enable the payer to properly reimburse the visit as well.

However, you write that your provider performed a frenotomy, not a frenectomy. The two terms are often used interchangeably, but they are different procedures. In a frenectomy, the physician removes the lingual frenum, the piece of skin that connects the tongue to the underlying bone and that can prevent a newborn from nursing or breastfeeding, a condition known as ankyloglossia.

A frenotomy, however, involves a physician making an incision in the frenum and relocating the attachment to the bone. In CPT^® coding, this is reported by using 41010 (Incision of lingual frenum (frenotomy)) instead of 41115.

Your evaluation and management (E/M) code selection for the second day of care, 99462 (Subsequent hospital care, per day, for evaluation and management of normal newborn), and the third-day discharge, 99238 (Hospital discharge day management; 30 minutes or less) are both correct, assuming the discharge was uncomplicated. So, too, is the circumcision code, 54150 (Circumcision, using clamp or other device with regional dorsal penile or ring block), assuming that this was the procedure your provider used.

But using 54150 on its own may also be a problem. That’s because the frenotomy has a 10-day global period attached to it. As your provider performed the circumcision during that global period, you may want to resubmit the claim with modifier 79 (Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period) appended to 54150. This will indicate that the same pediatrician, or another pediatrician in your group, performed a second, unrelated procedure on the same patient during the 10-day postoperative period for 41010.