Oncology & Hematology Coding Alert

Question: What's the practical significance of losing the starred designation in CPT 2004? For example, if I perform an E/M visit and minor skin biopsy (formerly a starred procedure), I would normally report 99213-25 and 19100. Now that CPT 2004 is effective and starred procedures are gone, what's the difference in coding?

Tennessee Subscriber

Answer: One of the problems with starred procedures was that CPT was stating that these codes did not include any E/M services. On the other hand, CMS was claiming that they included the preoperative services required to perform the procedure (if it had zero global days), and some of the starred procedures had 10 global days, according to CMS.

AMA decided to simplify the coding language by reducing everything to basic definitions. So, if you perform a procedure on the same day as an office visit, any E/M services would be included in the procedure code unless your documentation shows that the E/M was unrelated to performing the procedure. In this case, you would add 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 E/M code.

If the oncologist saw the patient the same day as or the day before surgery, you could only bill the E/M services using modifier -57 (Decision for surgery). But remember that the documentation must show that the office visit was unrelated to the procedure's performance (for example, obtaining informed consent, explaining the procedure to the patient, etc.).