Pediatric Coding Alert

Question: When we code an E/M with a starred procedure, the insurance company sometimes deletes the E/M code. For example, when wehave a young infant with fever,we code for catheterization of the urethra forobtaining sterile urine and an E/M code for the separately identifiable service of the physical and history. Do we also need to use modifier -25 with the E/M code?

Kentucky Subscriber

Answer: Starred procedures are a CPT convention that not all payers follow. When a star follows a surgical procedure, the following rules apply, according to CPT:

1. The service includes the surgical procedure only. Related pre- and postoperative services are not included in the service.

2. Report a combined starred procedure and visit as follows:

a. When you perform a starred procedure at the time of an initial visit (new patient) and this procedure constitutes the major service at that visit, report 99025 (Initial [new patient] visit when starred [*] surgical procedure constitutes major service at that visit) instead of the usual initial visit (99201-99205, New patient office visit) in addition to the starred procedure.

b. When you perform a starred procedure at the time of an initial or established patient visit involving significant, identifiable services, the appropriate visit is listed with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to the E/M code in addition to the starred procedure.

c. When the starred procedure requires hospitalization, list a hospital visit (e.g., 99221-99223, Initial hospital care) in addition to the starred procedure and its follow-up care. Although CPT does not specify appending modifier -25 to the hospital code, payers may require it.

3. Add all postoperative care on a service-by-service basis, such as an office or hospital visit cast change.

4. Add all complications on a service-by-service basis (as with all surgical procedures).

Based on the question's example, before performing a urethra catheterization you evaluate the patient including a physical and history. These evaluations lead you to decide that catheterization is necessary.

The scenario is an example of b. The pediatrician performed a starred procedure (53670*, Catheterization, urethra; simple) at the time of an established patient visit involving a significant, identifiable service (the physical, history and medical decision-making part of the E/M that led to the starred procedure). So you should report an office visit (99211-99215, Established patient office visit) appended with modifier -25 in addition to the starred procedure (53670).

If carriers continue to delete the E/M when you are following these rules, send them copies of the CPT rules (page 47 of the CPT 2002 and CPT 2003 manuals) and the operative report. The doctor's notes should clearly show the procedure and the office visit as separate and distinct.

Although the same general principles for starred procedures will still apply, CPT 2003 deletes catheterization code 53670. For 2003, report new codes 51701 (Insertion of non-indwelling bladder catheter [e.g., straight catheterization for residual urine]) and 51702 (Insertion of temporary indwelling bladder catheter; simple [e.g., Foley]), which are nonstarred procedures. You should still report the catheterization and the E/M appended with modifier -25 when the E/M represents a distinct, separately identifiable service from the catheterization. CPT 2003 deletes corresponding HCPCS level-two temporary G code G0002 (Office procedure, insertion of temporary indwelling catheter, Foley type [separate procedure]).

For nonstarred procedures combined with a distinct service, you may also consider appending modifier -59 (Distinct procedural service) to the lesser-valued procedure. Modifier -59 describes procedures/services that are not normally reported together but are appropriate under the circumstances, according to CPT Appendix AModifiers. You may use modifier -59 for a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury not ordinarily encountered or performed on the same day by the same physician. Many coding experts refer to modifier -59 as the modifier of last resort. You should use it only when no other modifier describes the situation.

Clinical information for You Be the Coder and Reader Questions provided by Mary Gutierrez, CPC, a certified pediatric coding specialist for West Texas Medical Associates in San Angelo; Victoria S. Jackson, CEO of Southern Orange County Pediatric Associates and owner of Omni Management, which provides practice management services for 15 medical offices in the Los Angeles area; and Richard Tuck, MD, FAAP, a pediatrician at PrimeCare of Southeastern Ohio in Zanesville.