Neurology & Pain Management Coding Alert

Did you know that you can 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 neurology practice.

Look for the '*' Before You Bill

When reporting starred procedures, you may 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 or relatively simple procedures such as injections. Common starred procedures familiar to neurology coders include lumbar punctures (62270) and chemodenervation (62280-62282).
 
Note: If a star appears next to the first code in a series of codes (for example, 20550*-20553), it applies only to the "starred" code, not to all codes in the 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 post-operative visits, CPT doesn't automatically bundle such visits to starred procedure codes, but allows you to charge separately for them if necessary," Callaway says.

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 neurologist performs diagnostic spinal puncture (62270*, Spinal puncture, lumbar, diagnostic) on an established patient. Prior to the tap, however, the neurologist performed an E/M service for the patient complaint that prompted the procedure. Because the 62270 is a starred procedure, the E/M service is not included, and you may report it separately. In this case, you would report 62270 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.' " Fulton says she usually has good results with such appeals.
 
Although a lot of 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," Fulton says. 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 (Office or other outpatient visit ...)," Callaway says. Payment for 99025 is generally in line with what a carrier might pay for 99201.

Watch for Payer-Imposed Global Periods

For example, the neurologist provides a neurolytic injection for pain management (for example, 62281*, Injection/infusion of neurolytic substance [e.g., alcohol, phenol, iced saline solutions], with or without other therapeutic substance; epidural, cervical or thoracic). The injection site becomes infected, and the patient returns to the surgeon's office within the payer-imposed 10-day global period. The physician drains, cleans and dresses the wound.
 
Medicare and others who follow Medicare guidelines will not reimburse separately for surgical wound treatment, even though CPT specifically states that postoperative 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."
 
But if the neurologist 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.
 
And, 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."