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E&M with Minor Procedure .

Meredith Posted Mon 11th of November, 2019 07:19:21 AM
If a NEW patient appointment is scheduled FOR THE PURPOSE OF ROUTINE CIRCUMCISION, and the evaluation and management note states in the HPI ; 2 month old male patient whose family desires circumcision. He was not circumcised at birth due to being born premature. OR another example: 4 week old male patient whose family desires circumcision. He was not circumcised at birth due to scheduling. Can you bill a E&M code along with the circumcision code AT THE SAME ENCOUNTER? 99202-25 54150 dx; Z41.2. OR 99203-25 54150 dx: N47.1 -N47.1 is a diagnosis for phimosis. "Phimosis is normal for the uncircumcised infant/child ". Is it acceptable to use N47.1 for a routine circumcision diagnosis?
SuperCoder Answered Tue 12th of November, 2019 03:51:16 AM

Hi Teresa,

 

Thank you for your question.

 

When the parent brings the baby (4 week old) in specifically for the circumcision, we will bill only that procedure (CPT 54160) on that day with diagnosis code Z41.2. Hope it helps.

 

Note: Circumcision has a 10-day global, which could make billing for other services within that period difficult.

Meredith Posted Tue 12th of November, 2019 06:45:22 AM
CPT 54150 "Circumcision, using clamp or other device with regional dorsal penile or ring block". This is the code for Plastibell and has a 0-day global. If the patient new, is it acceptable to bill a new patient visit along with CPT 54150?
SuperCoder Answered Wed 13th of November, 2019 06:46:23 AM

Hi, Teresa,

When a pediatrician performs a circumcision (such as 54150, Circumcision, using clamp or other device; newborn) and provides a subsequent hospital visit (99433, Subsequent hospital care, for the evaluation and management of a normal newborn, per day) or discharge service (99238-99239, Hospital discharge day management), many carriers reject the visit code. Insurers bundle the E/M code into the procedure due to pre- or postoperative days or procedure E/M inclusions.

However, you may append modifier 25 to the E/M code.

For example:

A pediatrician performs a circumcision using a clamp and later on the same day discharges the infant. You should report the circumcision (54150) and attach modifier 25 to the discharge code (99238-99239).

Point out that the E/M service is medically necessary whether the baby has a circumcision or not. This is the accepted standard of care for neonates in the hospital.

Also, Hospital policy requires the pediatrician to examine every infant prior to discharge to make sure he or she is well enough to go home.

 

Meredith Posted Fri 15th of November, 2019 05:45:42 AM
Thank you. I was actually inquiring about a circumcision that is done in the office. If the patient is NEW to the practice, Is it okay to bill an E&M or is it considered included in the work for the 54150?
SuperCoder Answered Mon 18th of November, 2019 07:44:16 AM

 

Hi Teresa,

Private-payer bundling of newborn circumcisions with E/M visits has caused decreased reimbursements for many pediatricians. Generally, insurance companies will not pay for a newborn circumcision in addition to a hospital visit. They will reimburse only for one code and deny the higher-paying code, the circumcision.

 

However, This unofficial bundling makes it impossible for pediatricians to be paid for both services they perform. The reason for the E/M is completely different from the reason for the surgery. All newborns must be examined for possible problems; some are circumcised as well. Modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) is appended to the E/M to reflect this distinction.

So, in office visit, Typically, before your urologist performs a circumcision he will provide some sort of E/M service or counseling concerning the procedure. "Circumcision counseling is pretty straightforward and usually only warrants a level two or three encounter. Provider will bill circumcision code and E/M with modifier 25 to get both the codes reimbursed. Also, check with your payer for E/M reimbursement.

Hope it helps.

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