Use Modifiers to Increase Payment for Starred Procedures
Published on Wed Nov 01, 2000
When is a small procedure, such as a biopsy or an injection, considered minor, and what does it mean if the procedure is starred? Understanding the difference between these terms can help practices determine whether they can perform evaluation and management (E/M) visits during starred procedures, and whether they can perform the starred procedure and another procedure on the same date of service.
Guidelines for Starred Procedures With E/M Visits
Starred procedures are relatively simple surgical procedures that are rarely associated with complications. These include lumbar punctures (62270*), ventricular punctures (61020*, 61026*, 61105*, 61107*), trigger point injections (20550*) and facet joint injections (20610*, arthocentesis, aspiration and/or injection; major joint or bursa (eg. shoulder, hip, knee joint, subacromial bursa). They are designated in CPT by an asterisk following the numerical code.
CPT offers specific coding rules and provides that the fee includes the starred procedure only. This means there are no global periods for starred procedures. If the starred procedure is carried out at the time of an initial or established patient visit involving significant identifiable services, the appropriate visit code can be listed with modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).
Use of modifier -25 can be carrier-specific, says Catherine Giblin, president of Medical Consultants of America, a healthcare practice management and billing firm in Haddonfield, N.J. Giblin advises that practices check with their insurers to determine if modifier -25 will be recognized when billing for E/M services with starred procedures.
For example, an established patient who has been experiencing tic-like movements in her face (307.20) comes into the office for a nerve block injection (64402). Before the injection, the patient complains of generalized muscle weakness and muscle inflammation (728.9). The physician decides to perform a muscle biopsy (20206). The practice can bill for the E/M to evaluate the muscle weakness and muscle inflammation (99212-99215) with 728.9 as a diagnosis. Modifier -25 can be attached to the E/M, and the nerve block injection can be billed using 64402 with diagnosis code 307.20.
As another example, abnormal cerebral spinal fluid (CSF) can indicate metastatic tumors of the brain. The neurologist may perform lumbar (62270) or ventricular punctures (61020) to remove some of the CSF for a cytopathological analysis to look for metastatic cancer cells. Separate from that, the physician performs a fair amount of evaluation and management by evaluating the need for the CSF puncture, evaluating the results of the CSF and determining the course of treatment. Again, with most carriers the E/M service would be appended with modifier -25.
Dealing With Code 99025
Billing for starred procedures that comprise most of the doctors visit [...]
