Neurology & Pain Management Coding Alert

Question: What's the practical significance of losing the "starred designation" in CPT 2004? For example, if I perform an E/M visit and a spinal puncture (formerly a starred procedure), I would normally report 99213-25 and 62270. Now that CPT 2004 is effective and starred procedures are gone, what's the difference in coding?

Tennessee Subscriber

Answer: The short answer to your question is: Your coding will not change for Medicare carriers. For private payers, you will have to begin appending modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to any E/M service provided on the same day as another procedure.

CMS did not follow CPT guidelines concerning formerly "starred" procedures such as 62270, (Spinal puncture, lumbar, diagnostic). CPT guidelines stated that these procedures included no pre- or postoperative services, while CMS claimed that all services include -- at a minimum -- the preoperative services required for the physician to perform the procedure. CMS even assigned a global period of 10 days to many so-called starred procedures -- meaning that the procedures included post-service care as well.

The AMA decided to simplify the coding language by reducing everything to basic definitions. Consequently, if you perform a minor procedure (typically defined as one with 0 or 10 global days) on the same day as an office visit, the payer will include any E/M services in the procedure code unless your documentation shows that the E/M was significant and separately identifiable. In this case, you would add modifier -25 to the E/M code. This now holds true for both Medicare and private payers (whereas formerly you would have needed to append modifier -25 for Medicare payers only).

If the neurologist saw the patient the same day as or the day before major surgery, you could only bill the E/M services using modifier -57 (Decision for surgery). But remember that the documentation must show the office visit involved medical decision-making for the procedure, not just standard parts of the global service (like obtaining informed consent or explaining the procedure to the patient).