How to get Paid for Circumcision

OBG Management: Page 25, October 1993.


Q. For years I used the diagnosis code 605 on claims for circumcision. Now those claims are being denied even after I submit documentation. What am I doing wrong?

A. You're using the wrong code. "Redundant prepuce and phimosis is what code 605 describes. If the diagnosis wasn't phimosis, the claim will be denied.

Instead use IDC-9-CM code V50.2 whenever you perform circumcision at the request of an infant's parents. But remember you still may not receive payment for insurer: Many simply do not reimburse for routine or ritual circumcision. (Also be aware that some payers don't accept V codes. If in doubt, ask.

Another issue is whether the procedure should be billed under the mother's insurance identification number or the child's. Medicaid requires that claims for circumcision be filed under the child's number. Often this means holding the claim until the baby has been assigned his I.D. number (which hardly seems worthwhile).

The reason for this requirement is that claims sent to Medicaid and some commercial payers are run through various computer "edits," among them a "sex edit" to verify the diagnoses or procedures specific to one gender match that of the patient. If the circumcision is reported under the mother's I.D. number, the male specific sex edit for the procedure will flag the claim for either manual review or automatic denial.

What about procedure codes for circumcision? Again, practice varies from payer to payer. Some managed care plans have developed their own codes for this procedure.

If the payer accepts the CPT codes, use one of the following:

       54150         Circumcision, using clamp or other
                     device; newborn

       54160         Circumcision, surgical excision
                     other than clamp, device or dorsal
                     slit; newborn

The easier way to check a payer's preferred codes and reporting practices is to make a habit of asking when you telephone to verify a patient's maternity benefits.

The items on this page are adapted from St. Anthony's Coding for Ob/Gyn Reimbursement, a newsletter of St. Anthony Publishing, Alexandria, Va.


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