Practice Management Alert

Question: A lot of our payers are starting to bundle the office visit when we bill a 17250 (chemical cauterization of granulation tissue [proud flesh, sinus or fistula]). The CPT book says it's a charge for a surgical procedure only. Shouldn't I be able to bill and be paid for both?
 
Indiana Subscriber

Answer: Technically, you should be able to be paid for both, since 17250 is a starred (*) procedure and the global surgical package may not apply according to CPT, says Marcella Bucknam, CPC, CCS-P, CPC-H, CCA, coordinator of the Health Information Management Program at Clarkson College in Omaha, Neb. That's because a starred procedure can have a GSP of zero to ten days. "However, it has been my experience that the starred procedure concept is a myth of the [American Medical Association] and that no insurance companies recognize these procedures as procedures that have no global component," she reports.
 
That means providers should treat 17250 and other starred procedures as though they weren't marked as such, Bucknam advises. "In other words, even if the global days are zero, one E/M on the day of the procedure will be bundled in unless modifier -25 is used." Of course, you can use the modifier only if you have clear documentation showing that a separately identifiable E/M service was performed and using it does not necessarily ensure separate payment. Some insurers always bundle any E/M into the same-day procedure, she notes. "Other insurers always bundle the E/M if the diagnosis code is the same as the diagnosis code for the procedure, modifier or not."
 
The only real way to protect yourself is to know ahead of time the requirements of all insurers with whom you do business, Bucknam stresses. And you have to hammer out any disagreements you have with them during the contract negotiation phase. Once you've signed on the dotted line, "you're pretty much stuck with their rules," she warns. "Also be sure that whoever makes the decisions about which insurance companies your practice participates with has information about any unreasonable denials."