Pediatric Coding Alert

Relief:  Recommendations on 54150, 64450-59 remain unchanged despite increased modifier 59 scrutiny

If you’re having success getting paid for a nerve block with circumcision using modifier 59, rest assured you can keep using this strategy.

The OIG recently reported its findings on modifier 59 use, says Vicky V. O’Neil, CPC, CCS-P, coding and compliance educator in St. Louis, Mo. “The study found that practices are rampantly misusing this tool.” The findings led CMS to encourage carriers to look closely at claims containing modifier 59 (Distinct procedural service)--and caused many pediatric coders to question their policies.

“When billing circumcision (54150, Circumcision, using clamp or other device; newborn) and peripheral (64450, Injection, anesthetic agent; other peripheral nerve or branch), I add modifier 59 to 64450,” says Kimberly Rourke, account specialist at High Desert Valley Pediatrics. Rourke has had success coding claims this way, but she doesn’t want her practice to be flagged for using modifier 59 in this situation.  These explanations will help you use this coding option with confidence. 1. Focus on Finding Coding That Works Don’t assume that increased scrutiny of modifier 59 claims means you should stop using the tool.

Many of the questions that Pediatric Coding Alert readers have asked regarding the modifier’s use seem to center around concerns of raising a potential audit flag rather than identifying correct coding options that work, says Richard H. Tuck, MD, FAAP, a nationally recognized coding speaker with PrimeCare of Southeastern Ohio. 2. AMA Backs Separate Nerve Block Reporting In the case of circumcision with nerve block, correct coding allows you to report both the procedure and the anesthesia. CMS policy for 54150 and 64450 does not, however, coincide with CPT guidelines.

The National Correct Coding Initiative edits, version 8.3, “inappropriately bundles the dorsal penile nerve block in the circumcision procedure,” Tuck says. CMS bases the edit, effective Oct. 1, 2002, on CPT’s surgical package, which includes “local infiltration, metacarpal/metatarsal/digital block or topical anesthesia.” But “a penile nerve block is not considered a local infiltration or topical anesthesia,” according to CPT Assistant August 2003, Volume 13, Issue 8. A nerve block is instead a regional anesthesia, which the surgical package doesn’t include.

Also: The AMA Resource Based Relative Value Scale Review Update Committee (RBRVS RUC) and the Centers for Medicare & Medicaid Services established the values for circumcision years before many physicians performed circumcisions with anesthesia, according to Coding for Pediatrics. Thus, insurers should reimburse pediatricians who do this procedure for the extra work, expense and risk involved in performing a dorsal penile nerve block.

Because the AMA [...]