Wiki Help please....99244 billed with circumcision performed on same visit.

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Trueladi33

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Hi All- I am new to pediatric urology billing and need help understanding this encounter. The provider is billing 99244 with modifier -25 , the patient was referred to him for a consultation for the evaluation of nb circumcision. He performed the circumcision in the same consult visit. He also added a modifier 25 with no other procedure codes listed on the claim. I don't think this is correct based on the CPT descriptor of 99244 and what consultation guidelines is stating. I'm not sure if an E/M office visit is more appropriate with the circumcision procedure added or if this should just be a circumcision procedure visit only. Any advice would be greatly appreciated. Thanks

3wk.o. male seen today in consultation at the request of ZZ Pediatric Center for the evaluation of newborn circumcision.
Np- nb circ/penis with wandering raphe
This has been present since birth. No pain associated with condition and no signs of infection. Patient is voiding and stooling regularly. No family history of urologic conditions. Child is otherwise healthy. No PMH or surgical history.

Impression:
Phimosis (primary encounter diagnosis)
Need for prophylaxis against sexually transmitted diseases
NEWBORN CIRCUMCISION:
- Discussed phimosis in the newborn, and that many times it resolves over time. I talked about etiologies of persistent phimosis. We talked about the relationship between diabetes, the uncircumcised penis, paraphimosis, and phimosis. We talked about the relationship between phimosis, balanitis, and voiding symptoms including urinary retention, pain and irritative voiding symptoms like urgency, frequency, dysuria and others.
- We talked about to various topical creams used to treat phimosis, and the surgery including circumcision. Through a shared decision-making approach, a thorough discussion regarding procedure, risks and benefits of circumcision were reviewed in detail with the parents. I explained the health benefits of circumcision include lower risks of acquiring HIV, genital herpes, HPV and syphilis. Circumcision may also lower the risk of penile cancer the risk of urinary tract infections in the first year of life. The risks, benefits, and some of the possible complications of the procedure were discussed with the patient including bleeding, wound infection, penile adhesions, trapped penis glans hypersensitivity, distal penile shaft scarring, and others. Alternative treatment options were discussed with the patient in detail.
- After all questions were answered, the parents request to proceed with the circumcision based on the preventative health benefits and give consent.
Plan:
Circumcision Procedure Note
Signed informed consent obtained/reviewed.
"Time Out" procedure completed; patient and procedure confirmed.
Infant was restrained in circumcision restraint tray in usual fashion and was provided 24% glucose solution po.
Approximately 3.0 ml of 1% lidocaine w/o epinephrine was infiltrated as a dorsal penile block and also a ring block to provide anesthesia of the distal penis and foreskin.
Foreskin was freed from phimotic adhesions to glans via gentle blunt dissection, foreskin was divided dorsally and then foreskin was removed using 1.3 Gomco circumcision tool.
Vaseline impregnated gauze was applied and the baby tolerated the procedure well.
Blood loss was minimal and estimated to be < 1ml.
Baby tolerated the procedure well.
Family was given instruction sheet and we answered all her questions regarding the postop care.
 
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Billing for all of the physician's services provided during the visit should not be billed with an E&M code alone as the CPT for the circumcision itself should be billed.
It seems like either of the follow codes would be appropriate for the procedure described in the note:
  • 54150-Circumcision, using clamp or other device with regional dorsal penile or ring block
    or
  • 54160-Circumcision, surgical excision other than clamp, device, or dorsal slit; neonate (28 days of age or less)
As for whether it is appropriate to bill a consult E&M 99242-99245 the 3 Rs of a consult need to be met. There is a great blog post from the AAPC titled Remember the "Three Rs" for Payer Accepting Consults, which I've linked here for your reference. As stated in the blog post, the 3 Rs are:
  1. Request from the treating provider (or a 3rd party such as an insurance company)
  2. Reason the requesting provider must state a specific reason for the consult
  3. Report from the consulting provider needs to be written with the consultant's opinion and the report needs to be sent back to the requesting provider
Based the statement "3wk.o. male seen today in consultation at the request of ZZ Pediatric Center for the evaluation of newborn circumcision." it might seem like this visit might be able to be billed as a consult with 99244, if the time or MDM criteria for a level 4 are met.

However, there are some questions that need to be answered before I would be able to say the E&M should be a consult versus a new patient office E&M.

Did the request from ZZ Pediatric Center actually state they were requesting a consultation, or did they send a referral for evaluation of the NB for circumcision because it seems unusual that a consult would be requested for such a routine condition and procedure for a NB. If they truly requested a consultation the first R Request has been met. The second R Reason is met since the note states the reason is for evaluation of the NB for circumcision.

The thing that trips providers up when wanting to bill for a consult is the third R, Report. The third condition may or may not be met but you don't mention if the provider sent a written report back with the consulting provider's opinion to the requesting provider or not. If there was no report with the consulting provider's opinion sent back to the requesting physician, then the E&M doesn't meet the criteria of a consult E&M.

I hope this information helps you figure out how to proceed with billing the claim for this patient encounter.
 
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Hi Corrine, thank you so much for responding and providing this great information. Looking back into the record the requesting provider only stated a referral bc the family desired circumcision. The encounter in questioned is labeled as a procedure visit (which added to my confusion) and I didn't see a written report being sent back to the provider. There was an post-op visit f/u sent back on a different encounter.
 
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Seems like you have a new patient E&M, not a consultation, which you can level based on time if the provider documented the amount of time spent on E&M services, not including any time spent on the procedure once the decision for surgery was made and consent was given by the parents. If the provider didn't document this time, then you'll have to level the E&M on MDM.

While it is unlikely the payer for this NB is Medicare the Medicare MLN booklet Global Surgery MLN907166 December 2023 indicates the following information regarding what is included in the surgical package for 0-day post-operative period, which 54150 & 54160 are, that indicates the E&M should be separately billable from the circumcision procedure itself. This information is on page 4 of the booklet I linked above for your reference.
1709661142093.png
Depending on the payer they may follow Medicare and the E&M would not require a modifier 25 to show the E&M is separate from the procedure but if they don't you may need to add modifier 25 to your E&M.

Additionally, since there was a post-op visit and there isn't a global package for this procedure you should be able to bill the post-op visit with your surgeon as well.
 
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CBLENNIE said:
Seems like you have a new patient E&M, not a consultation, which you can level based on time if the provider documented the amount of time spent on E&M services, not including any time spent on the procedure once the decision for surgery was made and consent was given by the parents. If the provider didn't document this time, then you'll have to level the E&M on MDM.

While it is unlikely the payer for this NB is Medicare the Medicare MLN booklet Global Surgery MLN907166 December 2023 indicates the following information regarding what is included in the surgical package for 0-day post-operative period, which 54150 & 54160 are, that indicates the E&M should be separately billable from the circumcision procedure itself. This information is on page 4 of the booklet I linked above for your reference.
View attachment 6897
Depending on the payer they may follow Medicare and the E&M would not require a modifier 25 to show the E&M is separate from the procedure but if they don't you may need to add modifier 25 to your E&M.

Additionally, since there was a post-op visit and there isn't a global package for this procedure you should be able to bill the post-op visit with your surgeon as well.
Click to expand...
ok, thank you this was very helpful
 
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