Neurology & Pain Management Coding Alert

Question: Our office manager says we shouldnt bill a new patient visit (99201-99205) with 20550 when the neurologist administers a ligament injection to a new patient. Can we get paid for the office visit and injection?

Maryland Subscriber

Answer: Because 20550* (Injection[s]; tendon sheath, ligament) is a starred procedure, CPT maintains different billing rules for it than for other, nonstarred codes. When a star follows a surgical procedure code in the CPT listing, the service includes the surgical procedure only. In other words, related pre- and postoperative services are not included in the procedure.
 
When a starred procedure constitutes the major service during a new patient office visit, report 99025 (Initial [new patient] visit when starred [*] surgical procedure constitutes major service at that visit) instead of the usual initial visit codes (99201-99205) in addition to the starred procedure.
 
If you perform a starred procedure during an initial or established patient visit involving significant, identifiable services, 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 E/M code and report it in addition to the starred procedure.
 
If the patient requires a hospital visit for the starred procedure, list a hospital visit code (for example, 99221-99233) in addition to the starred procedure and its follow-up care. Although CPT does not specify whether you should append modifier -25 to the hospital code, some payers may require it. Add all postoperative care (such as splint application or therapeutic exercise) on a service-by-service basis.
 
If carriers continue to deny the E/M service when you follow these rules, send them copies of the CPT guidelines (listed in the introductory notes to the surgery section) and your documentation. The physicians notes should clearly show the procedure and the office visit as separate and distinct.
 
Remember that not all payers follow the starred procedure guidelines (Medicare, in particular, does not recognize the starred procedure concept), and you should ask your insurers whether they maintain the same requirements for these services as CPT does. Some private insurers or workers compensation payers maintain especially strict requirements for billing starred procedures.