Primary Care Coding Alert

Starred procedures often refer to relatively minor surgical services. While most surgical codes include a package of services, starred procedures are an exception to the rule. For these reasons, not all carriers interpret the concept the same way and often assign different global periods to starred procedures, says an AMA coding representative. To further confuse the issue, Medicare may consider the starred procedures inclusive in a global package of services.

The AMA designated some procedures with a star in CPT to indicate that the office code 99025 (initial [new patient] visit when starred surgical procedure constitutes major service at that visit) should be used when providing this procedure to a new patient, explains Thomas Kent, CMM, principal of Kent Medical Management, a medical office management and coding consulting firm in Dunkirk, MD.

First, Medicare considers that most starred procedures have 0- to 10-day global periods, but because most of these procedures are simple, 0 is the usual period, Kent explains. He points out that if the procedure is not on an existing body opening, the global period is 0, while if a minor incision is made, the period is 10 days. A patient with a burn receives daily treatment (16020*, burns, local treatment, without anesthesia, office or hospital, small), so the care is a starred procedure with 0 global days and may be billed for each day of the treatment.

Second, the starred procedures stand alone with no other procedures bundled into them, Kent continues. When you see a starred procedure, there are no other procedures with it. If an unrelated procedure occurs at the same time, you also can bill for it.

Finally, starred procedures often have office visits associated with them, either to evaluate possible associated injuries (i.e., a neurological exam accompanying a head laceration) or an unrelated problem. Be sure to separate your diagnoses. For example, a 45-year-old established female patient sees her family practitioner for a sore throat, and receives debridement for a burn. The family doctor can bill the appropriate established patient visit (99212-99215) with modifier -25, as well as 16020* for the burn.

Starred Procedures for New Patients

When the starred procedure is carried out at the time of an initial or other visit involving significant identifiable services, such as the removal of a small skin lesion, list the appropriate E/M visit in addition to the starred procedure and its follow-up care. The starred procedure is not necessarily the major reason for, or the only service performed during, the visit, explains Kent Moore, manager of reimbursement issues for the American Academy of Family Physicians (AAFP).

But when the starred surgical procedure constitutes the major service during the initial visit, CPT says, use 99025 as an additional service instead of the E/M initial visit code (99201-99205). However, some family doctors wont report the starred procedure, but rather code an initial office visit, says Moore, a coding representative to the AMA. For instance, if a new patient walks in off the street with a cut arm, the family physician can code both 99025 and 12001* (simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities).

Kent says, however, that many carriers do not recog-
nize 99025 but prefer coding for an office visit with modifier -25, with or without a starred procedure.
When the starred surgical procedure constitutes the major service of a visit for a new patient, Greg Schnitzer, RN, CPC, CPC-H, CCS-P, audit specialist at the Office of Audit and Compliance with the University of Pennsylvania in Philadelphia, says also use 99025to get reimbursed for creating a medical chart for the patient even if no major examination took place.

Starred Procedures for Established Patients

The rules change for an established patient when he or she comes in for a follow-up and the starred procedure is the major or only reason for the visit. In this case, bill only for the starred procedure. For instance, a patient comes in with five skin tags for removal. Billing 11200* (removal of skin tags, any area, up to 15 lesions) is appropriate. The family physician already knows the patients history, so no additional E/M services have been performed, Moore says. An AMA coding hotline representative says that if you report an E/M visit and a procedureif the procedure was the intended and main reason for the visita carrier may have trouble recognizing both if performed on the same day. Instead, the starred procedure alone is appropriate.

On the other hand, Kent explains, if a patient comes in with hypertension and also asks to have skin tags removed, the family physician should bill for the office visit (99214) with diagnostic code 401.1 (benign hypertension), and 11200* and the diagnostic code 701.9 (unspecified hypertrophic and atrophic conditions of the skin). If the starred procedure requires hospitalization, the appropriate hospital visit along with the starred procedure should be used. Moore says this is rare since most starred procedures are minor and dont often result in hospitalization.

Follow-up Visits

Due to variable pre- and postoperative services associated with starred procedures, it is difficult to define a normal package, Moore says.

Since most starred procedures have a 0-day global period, if a patient returns to the office three days in a row for debridement, you can bill 16020* (local treatment of small burns without anesthesia in the office or hospital) every day that the patient is in the office for treatment, Kent explains.

Finally, if any complications ensue, they are also added on a service-by-service basis and are coded separately.