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.
Global Packages
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 [...]