Neurosurgery 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, or whether they can perform a 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), removal of tongs or halo applied by another physician (20665), and facet joint injections (20610, arthrocentesis, aspiration and/or injection; major joint or bursa, [e.g., 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; that is, there is no global period associated with it. If the starred procedure is carried out at the time of an initial or established patient visit involving significant identifiable services, the appropriate visit 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).

But 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 regarding whether modifier -25 will be recognized when billing for E/M services with starred procedures.

For example, a neurosurgeon sees a new patient through the emergency room and subsequently admits the patient. The patient suffers from head trauma and requires insertion of an intra-cranial pressure (ICP) monitoring bolt. The catheter insertion does not constitute the major service for this patients care. A lot of time was taken, and the documentation supports an extensive history and physical, examination and medical decision-making. ICP monitoring is a measure of the swelling in the brain. If the ICP gets too high, blood cannot get to the brain, and the patient may die. ICP requires close monitoring, especially in the initial days of trauma.

Physicians should code 99233 (subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of the three key components: a comprehensive interval history, a comprehensive examination, medical decision-making of high complexity; physicians typically spend 35 minutes at the bedside and on the patients hospital floor or unit) with a
-25 modifier for the admission, and then 61107 (twist drill hole for subdural or ventricular puncture; for implanting ventricular catheter or pressure recording device; starred procedure) for the procedure.

Also, an indicator of metastatic tumors of the brain can be abnormal cerebral spinal fluid (CSF). The neurosurgeon may perform lumbar (62270) or ventricular punctures (61020) to remove some of the CSF puncture for a cytopathological analysis to look for metastatic cancer cells. Separate from that, the physician performs a fair amount of E/M by evaluating the need for the CSF, 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 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 neurosurgeon from a general practitioner (GP) within the same practice, the neurosurgeon might perform a very short evaluation, because he or she has already received significant information about the patients condition from the GP. If the neurosurgeon is already aware that the patient needs removal of an implant such as a buried wire, rod or pin (20670), he or she might forego an evaluation and would perform the removal, which would constitute the major service at that initial patient visit. The practice could bill for 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, a coder who specializes in neurosurgical procedures, states that 99025 generally reflects certain non-cognitive services, such as setting up a record for a new patient who is just having a procedure and administrative tasks such as scheduling and getting prior authorizations.

Billing With Modifier -59

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, the procedure may need to be performed at multiple levels.

A starred procedure can be billed multiple times when it proves 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. Whether or not you also append modifier -51 (multiple procedures) following the 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, so adding it to your claim is no guarantee that youll get paid for both procedures youre performing, but if you can prove medical necessity for both procedures, you have a better chance of receiving the maximum level of reimbursement.