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November 4, 2003
CPT 2004 AND STARRED (*) PROCEDURES
The new CPT coding principles become effective January
1, 2004. A substantive change with significant potential
consequences for Emergency Medicine pertains to deletion
of the Starred (*) Procedure concept from CPT. The best
way to highlight the changes is to compare the current coding
principles (CPT 2003) and the new ones (CPT 2004).
CPT 2003
Currently CPT recognizes two types of surgical procedures:
Starred and "non-starred". For "non-starred"
surgical procedures, the CPT Surgical Package is included
in the procedure, and encompasses: a) essentially any
non-general anesthesia required for the procedure, b)
an E/M service subsequent to the E/M service at which
the decision for surgery was made, c) immediate post-operative
care, d) writing orders, e) evaluating the patient in
the postanesthesia recovery area, and f) typical postoperative
follow-up care. However, the Surgical Package concept
is not applicable to Starred Procedures. Therefore,
any components of the Surgical Package provided while
performing a Starred Procedure can be coded separately
(e.g., non-general anesthesia for which there is a CPT
code, typical postoperative care including wound checks
and suture removal, etc.)
When the Surgical Package is applicable, an E/M service
provided during the same encounter, or on the same day,
as a "non-starred" procedure can be separately
coded only when:
- The patient's condition required a significant, separately
identifiable E/M service above and beyond the other service
provided or beyond the usual preoperative and postoperative
care associated with the procedure that was performed.
The E/M service may be prompted by the symptom or condition
for which the procedure and/or service was provided. As
such, different diagnoses are not required for the reporting
of the E/M services on the same day. When such an E/M
service is reported, it can be identified by appending
a "-25" modifier.
- The E/M service is the one that resulted in the initial
decision to perform the surgery. When such an E/M service
is reported, it can be identified by appending a "-57"
modifier.
Because Starred Procedures are not encompassed by the
Surgical Package concept, E/M services provided at the
same encounter (or on the same day) as a Starred Procedure,
can be separately reported without any need for a modifier.
(CPT identifies two non-standard E/M codes for this purpose.
However, in a separate letter communication CPT has indicated
that in the ED, the ED E/M codes are to be used.)
It is worthwhile noting that Medicare does not utilize
the Starred Procedure concept, and instead assigns specified
"global periods" (i.e., 0, 10, and 90 days)
to procedures, and then categorizes such procedures as
"minor" (i.e., a global period of 10 days or
less) and "major" (i.e., a global period of
more than 10 days). By policy, Medicare will only recognize
an E/M service reported with a "minor" procedure
if such E/M has a "-25" modifier appended. Generally,
Medicare will not recognize any E/M service reported
with a "minor" procedure if a "-57"
modifier is appended, or if no modifier is appended. For
"major" procedures, Medicare will recognize
an accompanying E/M service with either a "-25"
or a "-57" appended. Generally, however, Medicare
will not recognize an E/M service accompanying a "major"
procedure if the E/M service has no modifier appended.
CPT 2004
Inasmuch as the Starred Procedures category is eliminated,
all procedures will be encompassed by the Surgical Package
concept. Therefore, the requirements described for "non-starred"
procedures above will now pertain for all surgical procedures.
Inasmuch as Medicare coding has not incorporated the
Starred Procedure concept, there will be no change for
Medicare code reporting.
The greatest potential impact of this revision is in the
2004 CPT coding of any E/M service accompanying a surgical
service. While the rules for "non-starred" procedures
are not new, they are somewhat removed from Emergency Medicine
due to the previous applicability to services not usually
performed by Emergency Medicine practitioners. As such,
these practitioners might be perplexed by having to make
the necessary distinctions among "E/M-25," "E/M-57,"
and those E/M-like activities that might not be separately
reportable.
And, once again, the effect of the CPT 2004 Starred Procedure
elimination upon relevant E/M coding for Medicare patients
should, at worst, be negligible.
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