Orthopedic Coding Alert

Orthopedists may be familiar with "starred" procedures, so named because the CPT manual attaches an asterisk (*) to their respective codes. Many of these starred procedures are relatively simple and can be performed in the office; however, coding them in combination with an E/M visit or for follow-up care is often not so easy.
 
Susan Callaway, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C., points out that CPT created the starred concept for smaller procedures because there were too many variables to say that a procedure would be the same with every patient. "The idea was that practices could bill preoperative and postoperative services separately," she says, "since service rendered could vary widely between patients."
 
The starred procedures that orthopedists are most likely to encounter include injections e.g., 20550* (Injection; tendon sheath, ligament, ganglion cyst) or 20600* (Arthrocentesis, aspiration and/or injection; small joint, bursa or ganglion cyst [e.g., fingers, toes]) and minor surgeries e.g., 26011* (Drainage of finger abscess; complicated [e.g., felon]) or 23700* (Manipulation under anesthesia, shoulder joint, including application of fixation apparatus [dislocation excluded]).
 
Note: CPT indicates that when an asterisk appears next to the first code in a series (i.e., 28190*-28193), the asterisk only applies to the code it appears next to and not the entire series.

The Surgery Guidelines section of CPT 2002 notes that the global surgical package concept does not apply to starred procedures: "The service as listed includes the surgical procedure only. Associated pre- and postoperative services are not included in the service as listed." 
 
Medicare and the majority of payers that follow Medicare's payment guidelines, however, assign most starred procedures a 10-day global period. The American Academy of Orthopaedic Surgeons (AAOS) even references the Medicare global fee periods in its Global Service Data 2002 guide.
 
The contradiction often causes problems for coders, whose claims of follow-up care to a starred procedure are usually denied.
 
For example, a physician performs an incision and drainage on a patient's foot (28001*, Incision and drainage, bursa, foot). The patient presents with complications at the surgical site within the 10-day global period and the physician irrigates and debrides the wound.
 
Medicare and most private carriers would not reimburse for the service. This contradicts CPT guidelines on starred procedures, which state: "Complications are added on a service-by-service basis (as with all surgical procedures)."
 
However, care rendered during a starred procedure's 10-day global period that is not related to the procedure is billable. If the patient underwent the 28001* but reported back five days later with a separate problem, the appropriate E/M code would be billed with modifier -24 (Unrelated evaluation and management service by the same physician during a postoperative period) appended.
 
Although the conflicting policies on starred procedures and global surgical packages can result in 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," says Beth Fulton, CPC, coding specialist at Orthopaedic Specialists of the Carolinas in Winston-Salem, N.C. "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."

Fulton says that starred procedures present a coding challenge when she tries to bill them with an E/M service. "When we bill an E/M visit with modifier -25 [Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service] 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, "but it is very frustrating to have to appeal to receive reimbursement."
 
Callaway says this problem relates to CPT's original intent in creating the starred codes. "According to CPT, if you did a starred procedure, it generally meant that no E/M visit would be billed," says Callaway. Instead, new patients who underwent a starred service on the same day as their initial visit were to be coded 99025 (Initial [new patient] visit when starred [*] surgical procedure constitutes major service at that visit) in addition to the starred code. The 99025 essentially 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 [Office or other outpatient visit for the evaluation and management of a new patient ]," she says. Payment for 99025 is generally in line with what a carrier might pay for 99201.
 
Callaway also points out, "In orthopedics, when a new patient is seen, the physician's evaluation will almost always meet the CPT requirements for reporting a new patient visit in addition to any starred procedures performed.
 
"The physician will need to figure out what the problem is and how it developed or occurred before deciding on a plan of treatment. This might not be true for a simple foreign-body removal, but it is especially true for injections."
 "I cannot imagine a doctor walking into an exam room and giving an injection to a patient he has never seen before and knows nothing about. It just makes sense that there was a significant identifiable evaluation done on a new patient before injecting that patient," Fulton says.
 
The message is that for a new or established patient, your physician must have met the requirements for a significant, separately identifiable E/M service on the same day of the procedure before billing 992xx-25.That means documentation must include a history, physical examination and medical decision-making (MDM) outlining treatment options.
 
The bottom line is that you're not supposed to report the new patient code unless all three key components (history, exam and MDM) are documented. Absent this level of documentation, report 99025.
 
For subsequent scheduled injections, a separate E/M visit is likely to be much harder to prove. Since the patient is presumably reporting for no other reason than the injection service, there is nothing else to report that day.    The patient would likely have to present with a new problem or an exacerbation of the problem now being treated.
 
For instance, if the patient was receiving a series of knee injections but reported for his next injection with a knee that was at first tender but is now swollen and feverish, a new review of symptoms would take place, as well as an analysis of what might have worsened the problem. In a scenario like this, documentation may justify a low-level E/M visit for an established patient.
 
Never overlook the importance of querying managed care carriers on their starred-procedure policies. Whenever possible, have language written into the contract that stipulates that CPT guidelines for starred procedures will be followed.