Urology Coding Alert

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  Question: Billing for fitting and insertion of a pessary support device requires use of code 57160, but this code is a starred procedure, meaning the service includes surgical procedure only. However, the CPT Surgical Guidelines do not appear to apply to fitting and insertion of a pessary. Why is this a starred procedure, and how should evaluation and management (E/M) codes be billed?

Karen Pearson,
Bend, Ore.


Answer: The short answer is: a) code 57160* is a starred surgical procedure because it is simpler than most other surgical procedures, and b) you cannot bill for E/M services with starred procedures such as 57160 precisely because they are simpler.

Starred procedures (those modified in the CPT manual with an asterisk) were created for that small group of codes that involve a readily identifiable surgical procedure but include variable preoperative and postoperative services, such as incision and drainage of an abscess, injection of a tendon sheath, manipulation of a joint under anesthesia, and dilation of the urethra.

Because of this, the usual surgical package concept does not apply. A surgical package comprises the listed surgical procedures covering the operation per se, local infiltration, metacarpal/digital block or topical anesthesia when used, and normal, uncomplicated follow-up care, according to the Surgical Guidelines.

For the E/M situation, the preoperative procedure gets starred when [it] is carried out at the time of the initial or established patient visit involving significant identifiable services, the appropriate visit is listed with the modifier -25 appended in addition to the starred procedure and its follow-up care, according to the CPT 2000 guidelines.

The preoperative procedure also is starred when [it] is carried out at the time of an initial visit [new patient] and this procedure constitutes the major service at that visit, procedure number 99025 is listed in lieu of the usual initial visit as an additional service.

It is important to note that starred procedures can be billed with other services, but only if they are not considered a part of the other service. Insurers may deny claims for fitting and insertion of a pessary if they consider it to be part of a larger surgical procedure. However, if fitting and insertion is unrelated to the other procedure, it can be billed separately.

This concept also applies to a question recently posed to Urology Coding Alert by Caroline Smith-Warfield, a billing supervisor in New Jersey. [...]