Eli's Rehab Report

Question: Our new office manager said we shouldn't bill a new patient visit ( CPT 99201 - 99205 ) with 20550* (Injection[s]; tendon sheath, ligament) when the physiatrist administers a ligament injection to a new patient. Can't we get paid for both the office visit and the injection?

New Jersey Subscriber

Answer: Because 20550 is a "starred" procedure, CMS maintains different billing rules for it than for other, nonstarred codes. 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. When a starred procedure constitutes the major service during a new patient office visit, report 99025 (Initial [new patient] visit when starred [*] surgical procedure constitutes major service at that visit) instead of the usual initial visit codes (99201-99205) in addition to the starred procedure.

3. If you perform a starred procedure during an initial or established patient visit involving significant, identifiable services, append 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 and report it in addition to the starred procedure.

4. If the patient requires a hospital visit for the starred procedure, list a hospital visit code (e.g., 99221-99233) in addition to the starred procedure and its follow-up care. Although CPT does not specify whether you should append modifier -25 to the hospital code, some payers may require it. Add all postoperative care (such as splint application or therapeutic exercise) on a service-by-service basis.

If carriers continue to deny the E/M service when you are following these rules, send them copies of the CPT guidelines (listed in the introductory notes to the surgery section) and your operative report. The physiatrist's notes should clearly show the procedure and the office visit as separate and distinct.

Remember that not all payers follow the "starred procedure" guidelines, and you should check with your insurer to determine whether they maintain the same requirements for these services as CMS does. Some private insurers or workers' compensation payers maintain strict requirements for billing starred procedures.

You Be the Coder and Reader Questions were reviewed by Laureen Jandroep, OTR, CPC, CCS-P CPC-H, CCS, director and senior instructor for the CRN Institute, an online coding certification training center.