Modifier 25 Continued:
Billing an E/M visit and a Starred Surgical Procedure
Published on Mon Mar 01, 1999
In the February issue of ECA (pages 9-10), we covered billing for an evaluation and management (E/M) service and a procedure performed on the same day by using the -25 modifier (significant, separately identifiable service performed by the same physician on the same day).
In most cases, if a patient presents to the emergency department with a complaint, the ED physician performs an evaluation, determines the course of treatment, and then treats the patient for the complaint.
For example, a child falls from a playground jungle- gym and is brought to the emergency department, where the physician on duty examines the child for injuries, orders specific x-rays, establishes a diagnosis of a simple laceration and contusion of the forehead.
In that situation, most coders know that the appropriate level E/M code (99281-99285) should be billed for the head to toe evaluation of the child, in addition to the code or codes for any procedures performed. In this case, the procedure would be laceration repair (12011*-simple repair of superficial wounds of the face, ears, eyelids, nose, lips or mucous membranes, 2.5 cm or less). The modifier -25 should be attached to the E/M code to ensure payment.
However, determining the correct use of the modifier -25 is complicated when starred surgical procedures are performed.
Starred Procedures in CPT
Surgical procedure codes are interpreted differently in CPT and the Medicare fee schedule.
CPT defines surgical procedures as starred
(without definite pre- and postoperative services) and non-starred procedures (with a definite set of pre-and postoperative services).
Non-starred procedures normally include a set number of days included in a global surgical period. Any treatment related to that procedure that is performed within its global period of dayswhich can range from zero to seven days for simple procedures and up to 90 days for complicated onesis deemed to be included in the code for that procedure. Most E/M services related to the surgery would be included in the procedure code.
But, starred procedure codes, which have no definite follow-up period assigned to them, include the procedure only and not any pre- or postoperative services.
CPT 1999 states: Certain relatively small surgical services involve a readily identifiable surgical procedure but include variable preoperative and postoperative services (e.g., incision and drainage of an abscess, injection of a tendon sheath, manipulation of a joint under anesthesia, dilation of the urethra). Because of the indefinite pre- and postoperative services, the usual package concept for surgical services cannot be applied. Such procedures are identified by a star (*) after the procedure number.
If a starred procedure is performed in the ED, an evaluation and management service could be billed based on the documented medical decision-making to account for the variable pre- and postoperative service, says Barbara Cole, RN, BSN, [...]
