Ob-Gyn Coding Alert

When is a small surgical procedure, such as a hysteroscopy or biopsy, considered minor, and when is it considered starred? Understanding the difference between those termsas well as who created them and whyhas major coding and billing implications, stresses Susan Callaway-Stradley, CPC, CCS-P, senior consultant for the Medical Group of Elliott, Davis and Co., LLP, in Augusta, GA, and the recently named American Association of Professional Coders (AAPC) 1998 Coder of the Year.

For example, when an ob/gyn performs an endometrial biopsy in your office, can you charge an office visit (99201-99215) in addition to the procedure code (58100*) by appending modifier -25 (separate, significantly identifiable service) to the E/M code? There are endless variations on this principal behind coding for starred procedures, points out Diana Barnes, coder for Laurel Ob/Gyn Associates, a three-physician ob-gyn practice in Charlotte, NC.

For example, Barnes asks, Because the asterisk in CPT indicates the code represents a surgical procedure only, can we also bill an E/M code when a colposcopy (57452*) is performed in the office? Likewise, can we bill an E/M code when an established patient needs dilation of the cervix (57800*) in order to obtain an adequate Pap smear sample?

Such questions cause stress to physicians and coders alike. The doctor is anxious to have a resolution to the questions and I am at a loss as to how it should be handled appropriately, Barnes says.

Why does this issue have ob/gyns and their coders in such a state? For one thing, modifier -25 may get the E/M service paid, but you might not want to cash the check just yet. The Office of the Inspector General (OIG) began auditing Medicare claims last fall for misuse of this modifier. In its plan of action, the OIG reported that physicians are deliberately billing this modifier in cases where it does not apply for the sole purpose of increasing reimbursement.

On the other hand, there are times when using modifier -25 with a starred procedure is perfectly appropriateand if you fail to bill it out of fear, then your practice is losing reimbursement to which it is ethically entitled.

Its vital that coders understand the difference between CPT and Medicare rules in order to bill correctly, says Melanie Witt, RN, CPC, MA, program manager for the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists (ACOG).

CPT Guidelines for Starred Procedures

Starred procedures are relatively simple surgical procedures that are rarely associated with complications. They are designated in CPT by an asterisk following the numerical code, she explains.

These procedures may or may not require postoperative care, and follow-up care may vary by procedure, condition or patient. (See list of ob/gyn-related CPT starred procedures on page 51). It is noteworthy that many other simple, uncomplicated procedures are not starred procedures, says Witt. (If CPT does not designate a procedure as a starred procedure, the guidelines about reporting an office visit in addition to a starred procedure do not apply.)

CPT states: Because of the indefinite pre- and post-operative services, the usual global package concept for [major] surgical procedures cannot be applied to starred procedures.

CPT offers specific coding rules, which can be summarized as follows: The fee includes the starred procedure only. Both the surgery and the accompanying visit are payable, with the following exception: An established patient visit on the same day as a starred procedure is generally not payable unless the visit is for a significant, separately identifiable problem.

For example, if an established patient was already scheduled for the biopsysay, for an abnormal Pap smearyou would not code an office visit in addition to the procedure code, Callaway-Stradley says.

However, if the starred procedure is performed at the time of an established office/outpatient visit (99212-99215) and involves a significant and separately identifiable service in addition to the biopsy, you can bill for it, Witt points out. For instance, the patient presents for the biopsy, but then informs the physician she felt a breast lump two days ago. You can also bill for the biopsy and an E/M service if the initial reason for the visit was a complaint that resulted in a biopsy being performed at the same time for the convenience of the patient.

You can also code for the office visit in addition to the biopsy if its performed during a new patient visit.

Note: Add modifier -25 to the E/M code (99201-99205) to identify the separate problem that warrants billing a patient visit in addition to the procedure.

The CPT guidelines also offer an alternative to billing a visit with a starred procedure with code 99025 (initial visit when starred surgical procedure constitutes major service). Witt notes, however, that this code is rarely recognized by third-party payers, and has the disadvantage of not describing the actual extent or level of the E/M service performed. (For related story see, When You Can Bill Starred Procedures with E/M Services Done During the Same Visit in the June 1999 issue of OCA on page 45.)

Medicare Rules for Minor Procedures

Medicare does not recognize starred procedures the same way CPT does. They call these relatively simple surgical procedures minor procedures, Callaway-Stradley says.

A minor surgery, under Medicare rules, is a surgical procedure with a 0- or 10-day postoperative, or global period. A 0-day global means additional billing is allowed starting the day after the minor surgery. A 10-day global means additional billing is not allowed until the 11th postoperative day.

Therefore, Medicares list of minor surgeries is not restricted to CPT starred procedures. For example, some laparoscopy codes (56300-56302, 56305-56309, and 56311-56313) are not considered starred procedures by the CPT; yet Medicare considers them to be minor procedures with a global period of 10 days. Hysteroscopy codes (56350-56356) are not starred procedures; however, with a 0-day global period, Medicare considers them minor procedures. Finally, other non-laparoscopic codes, such as lysis and destruction of lesions of vulva (56501-56515), are not CPT-designated as starred procedures, but are considered minor by Medicare.

The Medicare rules state that office visits cannot be billed if they take place on the day of surgery for minor proceduresunless the visit is unrelated to the surgery or it represents the visit at which the decision to do surgery was made. In either of these cases you would append modifier -25 to the E/M service.

Finally, Medicare carriers do not recognize 99025.

Editors Note: In the June issue of OCA, starred procedures were covered (When You Can Bill Starred Procedures With E/M Services Done During Same Visit, page 45); however, our coding experts pointed out the article did not cover the major principle behind the confusion of when to charge an additional E/M service: the discrepancy between CPT and Medicare. Commercial carriers are free to use a blended combination of these rules; therefore, check with your top five payers for their policy on separate procedures.