Coding Consult

What's in the stars?

Starred procedures can confound even expert coders. Here's what you need to know.

For many doctors, a star beside a procedure in the CPT manual signifies profound mystery. The first key to unraveling that mystery is simple, says Jan Rasmussen, president of Professional Coding Solutions in Eau Claire, WI: "Know what your payers' policies are."

A star (*) beside a procedure code in the CPT manual denotes a relatively minor surgical procedure that can require variable amounts of pre- and postoperative services. CPT doesn't assign the normal "global package" to these procedures as it does to other surgical procedure codes. Instead, the star indicates that only the procedure itself is included in the payment. You can code pre- and post-op care separately as necessary on a patient-by-patient basis.

While many private payers follow the CPT guidelines, Medicare does not embrace the "star" philosophy, instead assigning global periods of up to 10 days to the services it considers to be minor procedures. Services provided to the patient related to the procedure during that global period are covered under the fee for the procedure. Check with your local Medicare carrier to determine the global period for a particular starred procedure code.

Once you know whether your payer recognizes the CPT definition of starred procedures or follows Medicare guidelines, you can develop a coding strategy. (Some private payers in Florida have adopted their own set of rules for starred procedures, making the coding process all the more difficult.)

For example, a new female patient comes in with a sebaceous cyst on her shoulder. You perform a cursory exam limited to the immediate area and decide to drain the cyst. The history is focused only on the cyst, and the decision-making does not indicate that you ruled out any differential diagnosis. You perform the incision and drainage and tell the patient to return in one week for follow-up.

If the patient has coverage with a private payer that recognizes starred procedures, report 10060* (incision and drainage of abscess [e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia] simple or single) along with 99025 (initial [new patient] visit when starred surgical procedure constitutes major service at that visit).

The follow-up visit is coded at the appropriate established patient E&M level (99211-99215) with a diagnosis of V67.00 (follow-up examination following surgery, unspecified) or V58.3 (attention to surgical dressings and sutures), as appropriate. Or, if the patient returns with an infection at the cyst site at the follow-up visit, code the appropriate E&M with a diagnosis of 998.59 (other postoperative infection).

If the patient is covered by Medicare or a carrier that pays according to Medicare guidelines, report 10060* only. Medicare does not pay for 99025 in such a case. Because Medicare has assigned a global period of 10 days to 10060*, you won't be paid more for that follow-up visit a week after the procedure, even if care is related to a postoperative infection. "Medicare doesn't pay for any complications that do not require a return trip to the operating room," Rasmussen notes.

Established patients: when to bill an E&M

Coding a starred procedure performed on an established patient has different challenges. When the starred procedure is the major service at the visit, only the starred procedure itself can be coded whether the payer is Medicare or a private carrier. However, CPT says an E&M code can be used with a starred procedure if a significant, separately identifiable service is also provided at the same visit. Rasmussen notes, however, that carriers don't expect to routinely see an E&M coded on the same day as a starred procedure.

A good rule of thumb is to look at whether you performed a more extensive, medically necessary history/review of systems and examined areas outside the immediate body area where the procedure was performed in an effort to rule out differential diagnoses. Rasmussen notes, for example, that a separate E&M would not be coded for an established patient in the scenario above where the doctor drained a sebaceous cyst.

A separate E&M could be reported, however, for both Medicare and for payers that recognize starred procedures in the following case: A patient complains of shoulder pain. In the course of taking a history, you discover that the patient has had fevers, swelling, aches and pains in other joints, and a tick bite within the last year. You do a workup to rule out rheumatoid arthritis, osteoarthritis, and Lyme disease. At the end of the workup, you decide that the pain is probably from bursitis and give the patient an injection.

The injection is coded with 20610* (arthrocentesis, aspiration and/or injection; major joint or bursa [e.g., shoulder, hip, knee joint, subacromial bursa]), with a diagnosis of 719.41 (pain in joint; arthralgia; shoulder region). Bursitis cannot be coded because it is a "probable" diagnosis.

You can also report the appropriate E&M code, appended with the –25 modifier (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). Rasmussen notes that it's not necessary to list different diagnoses for the office visit and the starred procedure.

A separate E&M may also be coded for Medicare and private payers if the patient came to the office with another complaint, such as hypertension, and mentioned the shoulder pain and received an injection for it during the visit. Sharon O'Leary, coding coordinator at Physician Associates of Florida, a 70-physician practice, notes that the key to billing an E&M with a starred procedure is that the patient has a complaint that requires significant, separately identifiable services beyond the starred procedure. If the visit meets the required two out of three components for an E&M, she says, "We will bill for a low-level office visit with the –25 modifier."

Another scenario where you may charge a separate E&M for both Medicare and private payers is if you see the patient for shoulder pain, but ask him to return in two weeks for an injection if the pain persists. Charge the appropriate level of E&M for the first visit, and 20610* when the patient returns for the injection.

Make sure you get all you're entitled to

It's important to capture all associated costs and follow-up care for starred procedures. For example, the AMA noted in a clarification on starred procedures in the May 2001 CPT Assistant that anesthesia is among the services that can be reported separately from the starred procedure.

Additional reimbursement for a local anesthetic may be only a few dollars, but it can help cover the cost of those supplies, says Rasmussen. Medicare will not cover it, though, and other payers may follow Medicare's lead. But you might as well try.

Many doctors may also be missing out on revenue associated with starred procedures by not charging for suture removal and by not billing follow-up visits. O'Leary notes that charging for follow-up visits, which often carry a copay, can make some patients unhappy. However, she says, "unless the carrier has specific language that you may not bill a follow-up, I follow AMA guidelines and encourage our physicians to bill follow-up visits."

This information provided by The Coding Institute. For a free sample issue or information on how to subscribe to any of 29 specialty-specific coding newsletters, please contact The Coding Institute, 2272 Airport Rd. South, Naples, FL 34112; phone 800-508-2582; fax 800-508-2592; or visit www.codinginstitute.com.

 

Coding Consult: What's in the stars?. Medical Economics 2002;13:27.