Answer: You should choose the modifier based on when the surgery occurs in relation to the E/M. If the FP performs the circumcision and the E/M service on the same day, you should use modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).
When the FP provides a service that is unrelated to the circumcision during the circumcision's 10-day global period, you should instead use modifier -24 (Unrelated evaluation and management service by the same physician during a postoperative period).
Two examples show the appropriate use of both E/M service modifiers.
Same-day example: An FP does a dorsal penile nerve block for anesthetic purposes and circumcises (such as 54150, Circumcision, using clamp or other device; newborn) a newborn. Later, the FP discharges him from the hospital. The physician spends 20 minutes on discharge services. You would append modifier -25 to 99238 (Hospital discharge day management; 30 minutes or less) to designate the discharge as a significant, separately identifiable service from the circumcision- related E/M. The claim could read:
CPT codes: 99238-25 - significant, separate hospital discharge
54150-47 - circumcision with anesthesia by surgeon
64450-51 - multiple-procedure dorsal penile nerve block ICD-9 codes: V30.00 - Single liveborn, born in hospital, delivered without mention of cesarean delivery
V50.2 - Routine or ritual circumcision. Post-op scenario: Two days after an FP performs a hospital circumcision on a newborn, he sees the patient in the office for jaundice. For the office encounter, you would code an established patient office visit, such as 99213-24 (Office or other outpatient visit for the evaluation and management of an established patient ...) with 774.6 (Unspecified fetal and neonatal jaundice).
You would use modifier -24 because:
1. the office visit occurs within the circumcision's postoperative period
2. the E/M is for jaundice and is thus unrelated to the post-op period.