Neurosurgery Coding Alert

What if you could bill for services, such as follow-up E/M care, normally included in the global surgical package? When billing so-called "starred" procedures for payers that observe CPT guidelines, you can do just that - which can mean more reimbursement for your practice.

When you report starred procedures, charging separately for services normally included in the global surgical package is appropriate and warranted for some payers, even though coders are constantly warned against it. Starred procedures describe and include only the surgical procedure as listed in the CPT definition. "Associated pre- and postoperative services are not included in the service as listed," 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 or needle biopsies. Common starred procedures familiar to neurosurgical coders include some drainages and aspirations (for example, 61000-61070), spinal punctures (62272-62273) and nerve blocks (64400-64415).

Note: When an asterisk appears next to the first code in a series (e.g., 20550*-20553), the asterisk applies only to the code it appears next to, not the entire series. "The reasoning behind starred procedures was that practices could bill pre- and postoperative services separately, because the service rendered could vary widely between patients," says Susan Callaway, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C. "For instance, because postoperative visits might not always be required, CPT doesn't automatically bundle such visits to starred procedure codes, but allows you to charge separately for them if necessary."

Because starred procedures do not include any 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 neurosurgeon performs a diagnostic spinal tap (62270, Spinal puncture, lumbar, diagnostic) on an established patient. Prior to the tap, however, the surgeon performed a full E/M service related to the new patient complaint that prompted the spinal tap. 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 (you must select the appropriate E/M level as supported by the physician's documentation).

Reporting starred procedures and E/M services for the same date of service can present a challenge at times, says Beth Fulton, CPC, coding specialist at Orthopaedic Specialists of the Carolinas 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 a starred procedure to be reported in addition to an established patient visit when a significant, separately identifiable service is performed and modifier -25 is appended to the visit code.' " Fulton says she usually has good results with this type of appeal. In addition, you might consider stipulating in your contracts that managed-care payers agree to CPT guidelines for starred procedures.

The problem of E/M denials relates to CPT's original intent in creating the starred codes, Callaway says. "If you report a starred procedure, it generally means that you will not report an E/M in addition." 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 (Initial [new patient] visit when starred [*] surgical procedure constitutes major service at that visit) 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," Callaway says. Payment for 99025 is generally in line with what a carrier might pay for 99201.

Although 99025 is appropriate in some circumstances, you should not report it automatically. Often the surgeon will perform a significant E/M service for a new patient, for which you should receive fair compensation above that offered by 99025.

"In surgical practice, the physician's evaluation of a new patient will almost always meet the CPT requirements for reporting a new patient visit in addition to any starred procedures," Callaway says. "The physician will need to figure out what the problem is and how it developed or occurred before deciding on a plan of treatment."

"For instance," Fulton says, "I cannot imagine a doctor walking into an exam room and giving a tendon sheath injection [20550*, Injection(s); tendon sheath, ligament] to a patient he has never seen before and knows nothing about. It just makes sense that the surgeon performs a significant, identifiable evaluation on a new patient before injecting that patient." Nevertheless, you must be certain that the physician's documentation supports any E/M service code you select.

You'll probably have greater difficulty justifying an E/M service for subsequently scheduled injections for an established patient, however. Because the patient presumably visits for the injection only, you cannot report additional services at the same time. The patient would likely have to present with a new problem or an exacerbation of the existing problem before the surgeon's documentation would support a separate E/M service. For instance, a patient scheduled for a tendon sheath injection for carpal tunnel syndrome might complain of new symptoms of lower back pain during the visit, which substantiates a separate examination. In this case, you may report an E/M service (with modifier -25 appended) in addition to the scheduled injection.

Not all payers follow CPT guidelines for starred procedures, which can cause problems when you attempt to report follow-up care separately. Medicare, in particular, assigns most starred procedures a 10-day global period. For example, consider again the patient who undergoes a diagnostic spinal tap. The site of the puncture becomes infected, and the patient returns to the surgeon's office within the payer-imposed 10-day global period. The physician debrides and dresses the wound.

Medicare and others that follow Medicare guidelines will not reimburse separately for treatment of the surgical wound, 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, which would be extremely rare with starred procedures."

If the surgeon renders care unrelated to the starred procedure during the Medicare-imposed 10-day global period, however, 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 with modifier -24 (Unrelated evaluation and management service by the same physician during a postoperative period) appended, as well as any appropriate procedure codes.

Additionally, although the conflicting policies on starred procedures and global surgical packages may lead to denials, it 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 and don't have a reimbursement problem."