Primary Care Coding Alert

Question: When an FP performs a neonatal circumcision without anesthesia, a consultant said I should use modifier 52. I thought the circumcision code now included anesthesia. Would you explain this advice?

Colorado Subscriber

Answer: CPT contains codes that describe nonsurgical (54150, Circumcision, using clamp or other device with regional dorsal penile or ring block) and surgical (54160, Circumcision, surgical excision other than clamp, device or dorsal slit; neonate [28 days of age or less]) circumcision methods. Only the nonsurgical code includes the nerve block (64450, Injection, anesthetic agent; other peripheral nerve or branch).

FPs commonly use the nonsurgical method for neonatal circumcision. In 2007, CPT revised 54150 to include the regional dorsal penile or ring block that physicians usually administer prior to this type of circumcision. If an FP performs nonsurgical circumcision without dorsal penile or nerve block, you should append modifier 52 (Reduced services) to 54150, says a parenthetical instruction following the code in the CPT manual.

Tip: Let the payer reduce payment for the unperformed component.

To reflect the block's inclusion, the American Academy of Pediatrics was able to obtain increased physician work relative value units (RVUs) for 54150. Using the Medicare Physician Fee Schedule, 54150 pays about $197 in the office (5.19 RVUs x 2008 conversion factor 38.0870) and $106 in the hospital (2.79 RVUs x 38.0870).

Code 54160 does not include a nerve block (64450), which you may code separately. If the same FP provides the surgical excision circumcision and anesthesia, some payers may want you to indicate "anesthesia by surgeon" with modifier 47 (Anesthesia by surgeon) on 54160.