Neurology & Pain Management Coding Alert

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 with a new patient can be different. CPT 2000 states, when the starred procedure is carried out at the time of an initial new patient visit and this procedure constitutes the major service at the visit, 99025 (initial [new patient] visit when starred [*] surgical procedure constitutes major service at that visit) is listed in lieu of the usual initial visit as an additional service.

For example, if a patients care has been transferred to the neurologist from a general practitioner (GP) within the same practice, the neurologist might perform a very short evaluation because he or she has already received significant information about the patients condition from the GP. If the neurologist is already aware that the patient needs a trigger point injection (20550*), he or she might forego an E/M and perform the removal, which would constitute the major service at that initial patient visit. The practice could bill the 99025 in addition to the removal code, but experts warn that 99025 is not covered by Medicare or some private insurers.

Eric Sandham, CPC, compliance educator for Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno and a coder who specializes in neurological procedures, says that 99025 generally reflects certain noncognitive services, such as setting up a record for a new patient who is undergoing a procedure only or for administrative tasks such as scheduling and getting prior authorizations.

Billing Multiple Starred Procedures

Suppose the patient presents with the signs and symptoms of a severe disk disease through the lumbar region. A diagnostic injection procedure for diskography (62290*) may be performed. To get a radiogram of the disk or disks that may need surgical treatment, however, the procedure may need to be performed at multiple levels.

A starred procedure can be billed multiple times when it is medically necessary. You would have to add modifier -59 (distinct procedural service) to indicate that youre performing the starred procedure on different sites or during different sessions, Giblin advises. If you do not also append modifier -51 (multiple procedures) following modifier -59, the insurer will add modifier -51 to your claim and will pay the second procedure at a lower rate. Giblin advises practices to add modifier -51 to the cheaper procedure so that the more expensive procedure is paid at 100 percent.

Some insurers dont recognize modifier -59, says Giblin. Adding it to your claim is no guarantee that youll get paid for both procedures. But if you can prove medical necessity for both procedures, you have a better chance of receiving the maximum level of reimbursement.