ED Coding and Reimbursement Alert

Eliminated starred procedure concept docks payment

The whole will no longer equal the sum of its parts Jan. 1, when new CPT changes take the starred procedure concept off the menu.
 
In the past, a star symbol next to a procedure code - such as 12031* (Layer closure of wounds of scalp, axillae, trunk and/or extremities [excluding hands and feet]; 2.5 cm or less) - designated that the procedure did not include related services such as evaluation and management, follow-up care, certain anesthesia, or suture removal; you coded the other services separately, and got reimbursed separately.
 
But when the new year arrives, auxiliary services will be included in the procedure code. Because Medicare (and all payers that abide by Medicare's rules) never recognized the starred procedure concept, your treatment of starred procedure codes on those claims won't change.

Don't Dismiss E/M Codes Altogether

The elimination of starred procedures is likely to affect how you determine whether to report evaluation and management (E/M) services separately from surgical CPT codes. 
 
"For the vast majority of situations [in the ED] where a procedure must be performed, an evaluation and management must also be performed to determine the appropriateness of the procedure," because patients don't often walk in the door knowing the exact treatment they need, says Todd Thomas, CPC, CCS-P, president of Thomas & Associates in Oklahoma City. "Whether it is a fracture splinting, laceration repair, lumbar puncture, or control of epistaxis, the treating physician must decide what action to take," Thomas says.
 
At the very least, the ED physician will perform a medical screening exam to comply with the Emergency Medical Treatment and Active Labor Act. And while an E/M service subsequent to the decision for surgery might be considered part of the global package for formerly starred procedures, the initial E/M is not bundled into the procedure code - so when you append modifier -25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) or -57 (Decision for surgery), you should receive separate reimbursement.

Consider History When Billing Separate E/M

"If all the physician does is a procedure, then that is all you can bill for," Thomas says. But in the ED, most of the time that's not the case. And you don't need treatment of an additional body part or a separate complaint in order to bill an E/M, he says. For example, suppose a patient presents in the ED with a laceration to her arm from a fall.
 
"The physician is going to need to do more than just repair the wound," Thomas says. "He's going to need to ask some history questions as to how the accident happened. He's likely going to ask some review-of-systems questions" - such as whether the patient has dizziness or other symptoms - "to make sure there isn't anything else going on that could have precipitated the fall in the first place."
 
When the doctor examines this patient, he'll be looking at more than the cut on the arm, Thomas says. "I would suspect that he might look at the elbow, shoulder, or wrist joints to make sure nothing happened there that the patient may not be complaining about in the history. If the cut is deep enough, he's probably checking for ligament or tendon involvement."

Justify Additional H&P

Ultimately, the rules haven't changed much, except that CPT has left determining global periods up to individual carriers. But coders and physicians worry that private payers may misinterpret the removal of the starred procedures as leeway not to pay them for services excluded from the global surgical package, even with appropriate modifiers. 
 
In addition, the requirement to assign an accompanying E/M code to previously starred procedures may get sticky when medical necessity for an additional history and physical isn't evident to the coder. And ED physicians may not be accustomed to providing documentation that clearly supports an additional E/M assignment, says Tracie Christian, BS, CPC, CCS-P, director of coding, technical, and training services at ProCode/The Schumacher Group in Dallas. So coders and physicians will need to watch these claims carefully.
 
As always, Christian says, "Complete and thorough documentation is the coder's key to success. And in these cases, additional documentation reflecting coexisting conditions or injuries that are being evaluated concurrently at the time of presentation will greatly assist with proper code assignment."

Keep an Eye Out for These Key Areas

Nerve blocks. Some payers may already deny separate payment for nerve blocks performed with minor surgical procedures. And with CPT's deletion of the star designation, convincing your carrier that you should receive separate reimbursement for these anesthesia services could be even more difficult.
 
Post-Op Wound Repair Services. You may also  encounter more carrier resistance when you try to get separate payment for services like wound checks and packing removal - and certainly suture removal, if you were even reporting it in the past. Carriers will probably evaluate these services individually, and more critically, before granting you separate payment for certain postoperative wound repair services.