Ophthalmology and Optometry Coding Alert

Get ready to justify modifier -25 for E/M after minor surgeries

If your practice performs lots of minor surgeries, prepare to get starstruck - the star has been struck from the new 2004 CPT book for those procedures. 
 
The CPT Editorial Panel is eliminating the "starred" designation from all surgical procedures. Coding experts say this marker was always a source of confusion. But they worry that the change will mean a drop in reimbursement for physicians. Unless the relative value units (RVUs) for these procedures go up to compensate for the new global period, providers will end up losing money, says Robert Burleigh with Brandywine Consulting in Malvern, Pa. "You've lost on one end and not gained on the other."
 
In the past, you may have billed for a procedure that reimbursed $45 and an evaluation and management visit that paid $40. Now, unless you can justify that separate E/M visit, you may be stuck billing only for the $45 procedure. Even if the reimbursement for that procedure rises to $55 to compensate, you'll still be out $30.
 
"As a practical matter, the practices will be resentful of the newest assault on their income," Burleigh says.
 
The idea behind the starred procedure designation was that there's no "typical" situation with minor surgeries as with major surgeries, says Susan Callaway, an independent coding auditor and trainer in North Augusta, S.C. "Each case might have a different amount of pre- and post-op work depending on the needs of the patient."
 
But coders often stopped reading there and didn't realize you couldn't automatically bill an E/M visit before and after every single minor surgery. The CPT book went on to explain that you had to decide before billing whether there was a significant E/M provided.
 
The removal of the starred procedures means the CPT panel finally recognized that "no one uses starred procedures as defined by CPT," Callaway says. In particular, all post-op services, including wound checks, were supposed to be separately billable. But many payers have bundled them with starred procedures.
 
Because it didn't reflect the realities of coders' work, the starred-procedure concept "created more problems than it was worth," Callaway says. It seems as though the CPT panel has realized "that life is easier for everyone if the concepts in the book reflect more closely the realities of day-to-day work with carriers." The starred procedure "is an extinct concept," and leaving it in the book "just confuses everyone," Callaway says.
 
"It's going to put a lot more pressure on crisp, complete documentation that will appropriately justify the -25 modifier (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service)," Burleigh says.
 
Without the starred designation, all of these procedures "will essentially be global," forcing providers to justify E/M services using a modifier.
 
It won't necessarily make life easier to use modifier    -25, Callaway agrees. Even under the old starred- procedure rubric, the use of that modifier was always interpreted the same way. "Any carrier-specific interpretation is always up to them, and they are not likely to change."
 
"The global assignment for what were previously starred procedures is going to be very short," Burleigh says. It will probably be one to 10 days.