International Classification of Diseases, 10th Revision, Clinical Modification ( ICD-10-CM) and Current Procedural Terminology ( CPT ®) codes for circumcision of a neonate are as follows: Note: If circumcision using a clamp or other device is performed without dorsal penile or ring block, append modifier 52 (reduced services) to 54150.
Encounter for routine and ritual male circumcision 1 Z41.2 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. 2 The 2021 edition of ICD-10-CM Z41.2 became effective on October 1, 2020. 3 This is the American ICD-10-CM version of Z41.2 - other international versions of ICD-10 Z41.2 may differ.
Codes for initial care of the normal newborn include: CODES FOR THE INITIAL CARE OF THE NORMAL NEWBORN. 99460. Initial hospital or birthing center care, per day, for E/M of normal newborn infant. 99461. Initial care per day, for E/M of normal newborn infant seen in other than hospital or birthing center. 99463.
Note: If circumcision using a clamp or other device is performed without dorsal penile or ring block, append modifier 52 (reduced services) to 54150. If circumcision performed by surgical excision other than clamp, device, or dorsal slit takes place outside of the neonatal period, see code 54161.
Encounter for change or removal of nonsurgical wound dressing. Z48. 00 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. The 2022 edition of ICD-10-CM Z48.
Z41.2ICD-10 Code for Encounter for routine and ritual male circumcision- Z41. 2- Codify by AAPC.
Z41.2What are the appropriate procedure and diagnosis codes for newborn circumcision?ICD-10-CM code: Z41.2Encounter for routine and ritual male circumcisionCPT codes: 54150Circumcision, using clamp or other device with regional dorsal penile or ring block1 more row•Dec 1, 2015
ICD-10-CM Code for Encounter for surgical aftercare following surgery on specified body systems Z48. 81.
Z41. 2—Encounter for routine and ritual circumcision would be used when an infant presents for circumcision after the birth episode and there is no medical cause identified for the circumcision. In other words, if the parents wish to have their baby circumcised, Z41.
There are two main circumcision medical billing codes. Although one code is used more often, there are two that are acceptable. The two medical billing codes used for newborns circumcision are 54150 and 54160. 54150 means, circumcision, using clamp or other device; newborn.
CPT codes 54162 and 54163 will be reported for revision of circumcision or complication developed in post-circumcision.
The physician diagnoses excess foreskin due to inadequate circumcision. Codes N99. 89 (other postprocedural complications and disorders of genitourinary system) and N47. 8 (other disorders or prepuce) are reported.
Answer: For circumcisions performed in the office on a newborn, you should bill 54150 (Circumcision, using clamp or other device with regional dorsal penile or ring block).
Follow-up. The difference between aftercare and follow-up is the type of care the physician renders. Aftercare implies the physician is providing related treatment for the patient after a surgery or procedure. Follow-up, on the other hand, is surveillance of the patient to make sure all is going well.
Follow-up visits, like initial visits, should be coded using the appropriate evaluation and management (E/M) code (i.e., 99211–99215). Given the limited interaction with the patient and limited work involved, the level of service is likely to be low (e.g., 99211 or 99212).
Post-operative visits should be reported with CPT code 99024 when the visit is furnished on the same day as an unrelated E/M service (billed with modifier 24).
Aftercare visit codes cover situations occurring when the initial treatment of a disease has been performed and the patient requires continued care during the healing or recovery phase, or care for the long-term consequences of the disease.
The codes for factors influencing health and contact with health services represent reasons for encounters. In ICD-10-CM, these codes are located in Chapter 21 and have the initial alpha character of “Z,” so codes in this chapter eventually may be referred to as “Z-codes” (just as the same supplementary codes in ICD-9-CM were referred to as “V-codes”). While code descriptions in Chapter 21, such as aftercare, may appear to denote descriptions of services or procedures, they are not procedure codes. These codes represent the reason for the encounter, service or visit, and the procedure must be reported with the appropriate procedure code.
Codes for encounters for antineoplastic radiation, chemotherapy and immunotherapy (Z51.0, Z51.1-) are assigned if the sole reason for the encounter is antineoplastic therapy – even if the patient still has the neoplastic disease.
When the reason for an encounter is aftercare following a procedure or injury, the 2012 ICD-10-CM Official Guidelines and Reporting should be consulted to ensure that the correct code is assigned. Codes for reporting most types of aftercare are found in Chapter 21. However, aftercare related to injuries is reported with codes from Chapter 19, using seventh-character extensions to identify the service as aftercare.
Lauri Gray, RHIT, CPC, has worked in the health information management field for 30 years. She began her career as a health records supervisor in a multi-specialty clinic. Following that she worked in the managed care industry as a contracting and coding specialist for a major HMO. Most recently she has worked as a clinical technical editor of coding and reimbursement print and electronic products. She has also taught medical coding at the College of Eastern Utah. Areas of expertise include: ICD-10-CM, ICD-10-PCS, ICD-9-CM diagnosis and procedure coding, physician coding and reimbursement, claims adjudication processes, third-party reimbursement, RBRVS and fee schedule development. She is a member of the American Academy of Professional Coders (AAPC) and the American Health Information Management Association (AHIMA).
Aftercare and Follow-up: ICD-10 Coding 1 The aftercare Z code should not be used if treatment is directed at a current, acute disease. 2 The aftercare Z codes should also not be used for aftercare for injuries.
The aftercare Z codes should also not be used for aftercare for injuries. Certain aftercare Z code categories need a secondary diagnosis code to describe the resolving condition or sequelae. For others, the condition is included in the code title.
Evaluation and management (E/M) services provided to normal newborns in the first days of life prior to hospital discharge are reported with Newborn Care Services codes. Codes for initial care of the normal newborn include:
After the newborn has been discharged to home, it is common practice to see the infant to assess for jaundice or any feeding problems. Coding for this service depends on the provider of the service and whether the visit is in follow-up to an already identified problem or screening for problems.
Family physicians who perform newborn circumcision should separately report this service. Codes for circumcision procedures include:
When providing E/M services to other than normal newborns, choose the level of care based on the intensity of the service and status of the newborn. Care of newborns who are not normal but do not require intensive services may be reported with codes for initial hospital care (99221-99223).
When the newborn is critically ill or injured, codes exist for reporting of services provided during interfacility transport, initial critical care, and subsequent critical services.
Critical care services delivered by a physician, face-to-face, during an interfacility transport of critically ill or critically injured pediatric patient, 24-months of age or less, are reported based on the time of face-to-face care beginning when the physician assumes primary responsibility at the referring hospital/facility and ending when the receiving hospital/facility accepts responsibility for the patient's care.
The initial day of critical care for the evaluation and management of a critically ill neonate, 28-days of age or less, is reported with code 99468. Only one physician may report this code.