Pediatric Coding Alert

Question: When a child is born, the hospital stay is only three days. Therefore, we do the subsequent care, circumcision and penile nerve block all on the same day. I use modifier 59 on the nerve block code. Which E/M codes require modifier 25 for the following claims:

• 10/1/06 First day newborn  99431
• 10/2/06 Sub. newborn care 99433
• 10/2/06 Circumcision  54150
• 10/2/06 Penile nerve block  64450-59
• 10/3/06 Hospital discharge  99239

Answer: According to CPT Guidelines , which may vary from payer requirements, you do not need modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) on any of the above service codes. To code the above hospital services, remember these modifier 25 rules:

1. Do not use modifier 25 when you perform an E/M service alone. Modifier 25 applies only to claims that involve a same-day service and procedure or two same-day services. Therefore, when you are reporting only normal newborn care and hospital discharge on days one and three, no modifier is necessary.

2. Traditionally, you should reserve modifier 25 for E/M services performed with major procedures, those containing 10- or 90-day global periods. CPT has no  language that makes a modifier necessary when coding an E/M service (such as 99433, Subsequent hospital care, for the evaluation and management of a normal newborn, per day) with a minor procedure (such as 54150, Circumcision, using clamp or other device; newborn), which contains zero global days. 

3. Be sure to check with insurers for their individual modifier 25-procedure policies. Private payers may require modifier 25 on 99433 with 54150 due to its pre-2005 designation as a 10-day global period procedure in the National Physician Fee Schedule Relative Value File.

4. If you do code 99433-25, documentation must support that the service is significant and separately identifiable from 54150. Using two documentation entries--one to describe the subsequent newborn care and one for the circumcision and nerve block--will help substantiate reporting the separate service and provide support if you have to appeal the claim. You are correct to append modifier 59 (Distinct procedural service) to the penile nerve block code to override the NCCI edit that incorrectly bundles 64450 into 54150. (See “Sharpen Your Circumcision Coding With These 4 Pointers” in the September 2006 PCA.)

Aside from payer variances, optimal coding for the above three-day hospital stay would be as stated above: