Internal Medicine Coding Alert

Published on Thu Jan 01, 2004 PDF

After Jan. 1, 2004, if you report your internist's incision, excision and repair services using the starred procedure guidelines you can expect the denials to start rolling in.
 
CPT 2004 deletes starred designations for incision, excision and repair codes (10040-10160, 11000-11901, and 12001-12051), which means to bill an E/M service, you'll have to attach modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code.
 
Under the old CPT rules, the star designation was supposed to mean that a minor surgical procedure, such as 12001 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.5 cm or less), represented only the surgical services. For example, physicians could bill for a next-day E/M service.
 
But Medicare and many other private insurers bundled the two services and didn't pay for the E/M service without a modifier, says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.
 
For instance, CMS attached a 10-day global period to 12001. This 10-day period meant that Medicare would not pay for a physician performing an E/M service or any procedure that was related to the simple repair within the 10-day time frame.
 
CPT 2004 has changed 99024 (Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason[s] related to the original procedure) to clarify that you should use this code to report services in the surgical package. This means payers won't separately reimburse for the services.
 
You can no longer report E/M code 99025* (Initial [new patient] visit when starred surgical procedure constitutes major service at that visit) in 2004, because CPT deletes the code. Typically, coders reported 99025 when the physician performed a starred procedure, such as a simple repair (12001), on the same day as a patient's initial visit.