General Surgery Coding Alert

What if you could bill for services, such as follow-up E/M care, that are part of global surgical packages? When billing so-called "starred" procedures for payers that observe CPT guidelines, you can do just that - which can mean more reimbursement for your surgery practice.

Look for the '*' Before You Bill

When reporting starred procedures, you may appropriately charge separately for services normally included in the global surgical package for some payers, even though coders are constantly warned against it. Starred procedures describe and include only the surgical procedure as described by the CPT definition. "Associated pre- and postoperative services are not included in the service," according to CPT surgery guidelines.
 
You can identify starred procedures easily by looking for an asterisk (*), or "star," to the right of the code in CPT. Most often, starred codes represent minor procedures such as injections or needle biopsies. Common starred procedures familiar to surgical coders include introduction of intracatheter or central venous catheters (36000, 36488-36489), injection of sclerosing solution to treat hemorrhoids (46500) and various biopsies (for instance, 47000, Biopsy of liver, needle; percutaneous).
 
Note: When an asterisk appears next to select codes in a series (e.g., 46900*-46922), the asterisk applies only to those codes it appears next to, not the entire series.
 
"CPT created starred procedures because services could vary widely from one patient to the next. By 'unbundling' pre- and postoperative services from the procedure, practices could report only the necessary services," says Susan Callaway, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C. "For instance, because not all patients require postoperative visits, CPT doesn't automatically bundle such visits to starred procedure codes, but allows you to charge separately for them if necessary."

Apply Modifier -25 for Same-Day E/M Services

Because starred procedures do not include pre- or postoperative services, you may report an E/M service at the same time, but only if you append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the appropriate E/M code, according to CPT.
 
For example, the surgeon performs an incision and drainage (I&D) for a superficial perianal abscess (46050) on an established patient. Prior to the I&D, however, the surgeon performed an E/M service for a new patient complaint that prompted the procedure. Because the 46050 is a starred procedure, the E/M service is not included, and you may report it separately. In this case, you would report 46050 and 9921x-25.

Anticipate E/M Service Denials
 
Reporting starred procedures and E/M services for the same date of service can present a challenge at times, says Beth Fulton, CPC, a coding specialist in Winston-Salem, N.C. "When we bill an E/M visit with modifier -25 along with a starred procedure, carriers sometimes deny the E/M," she says. "I appeal those denials with a little blurb along the lines of, 'CPT guidelines will allow billing of a starred procedure in addition to an established patient visit with modifier -25 when the physician performs a significant, separately identifiable service.' "
 
Although some payers will refuse a standard E/M service with a starred procedure, many will pay for 99025 (Initial [new patient] visit when starred [*] surgical procedure constitutes major service at that visit). "If you report a starred procedure, it generally means that you will not report an E/M in addition." Instead, she says, for new patients who undergo a starred service on the same day as their initial visit, payers anticipate that you will select 99025 in addition to the starred code. Code 99025 represents the cost of setting up a new patient (establishing a chart, taking vital signs, etc.). "A noticeable number of carriers will pay for 99025 but not for 99201," Callaway says. Payment for 99025 is generally in line with what a carrier might pay for 99201.

Watch for Payer-Imposed Global Periods

Not all payers follow CPT guidelines for starred procedures, which can cause problems when you attempt to report follow-up care separately. Medicare, in particular, assigns most starred procedures a 10-day global period.
 
For example, the surgeon repairs a superficial wound (12001*, Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.5 cm or less). The wound repair site becomes infected and the patient returns to the surgeon's office within the payer-imposed 10-day global period. The physician debrides and dresses the wound.
 
Medicare and others that follow Medicare guidelines will not reimburse separately for surgical wound treatment, even though CPT specifically states that post-operative care and complications "are added on a service-by-service basis." "You won't get the payer to budge on this," Callaway says. "Medicare won't pay for related postoperative care during the [10-day] global period unless it requires a trip to the operating room."
 
If the surgeon provides care unrelated to the starred procedure during the Medicare-imposed 10-day global period, you may report it separately. For instance, if the patient underwent a spinal tap but reported back five days later with a separate problem, you may report an E/M service and append modifier -24 (Unrelated evaluation and management service by the same physician during a postoperative period) to the appropriate E/M service code.
 
Although the conflicting policies on starred procedures and global surgical packages may lead to denials, this is not an issue for injection codes, which have zero follow-up days even with Medicare. "We typically don't have a problem with billing any follow-up care," Fulton says. "If the patient comes back after an injection, we bill that visit on a service-by-service basis."