2011 CPT Coding Updates

1. 2011 CPT Coding Updates Sandy Giangreco, CCS, CPC, CPC-H, CPC-I, COBGC, PCS Compliance Audit Manager

2. CPT 2011 Always check for errata – http://www.ama-assn.org/ama1/pub/upload/mm/362/cpt-2011-corrections.pdf

3. Agenda for Session • Time-Based Coding Clarifications • E/M Services • Debridement • Sentinel Node Biopsy • Musculoskeletal Changes • Otolaryngology/Bronchoscopy • Cardiothoracic Surgery • Endovascular Coding Changes • Digestive System • Neurology Changes • Ophthalmology • Radiology • Laboratory • Medicine Chapter

4. Time-Based Coding Clarifications • Time is face-to-face unless otherwise specified (as in inpatient being floor/unit time) • Time units are reported once the midpoint is passed (Careful: CMS is different! Time must be met or exceeded) • Never count time twice • Overnight services clarified • Continuous services – report subsequent unit • Discontinuous services – report initial unit for second day

5. Evaluation and Management Services New E/M tables have been added that begin on page xix of the 2011 CPT book • Can be very helpful in assisting clients in follow up education or monitoring Guidelines: Time • The E/M guidelines defining Time have been updated to match the new rules on time-based coding and also to clarify the requirements for face-to-face versus non-face-to-face time

6. Subsequent Observation Care New codes – previously coded with unlisted codes or office visit codes • Reimbursement issues/patient relations issues • 99224 – equivalent to 99231 • 99225 – equivalent to 99232 • 99226 – equivalent to 99233

7. Debridement • 11040 and 11041 have been deleted • Use 97597 and 97598 instead • Eliminates confusion between surgical debridement codes and active wound care management with selective debridement

8. Size Matters! • Base code is now for 20 sq cm or less • Add-on code for each additional 20 sq cm CPT Professional 2011, page 58 – “When performing debridement of a single wound, report depth using the deepest level of tissue removed. In multiple wounds, sum the surface area of those wounds that are the same depth, but do not combine sums from different depths.”

9. Debridement 11042 - Debridement, subq; first 20 sq cm or less • #+11045 – each additional 20 sq cm or less 11043 – Debridement, muscle or fascia; first 20 sq cm or less • #+11046 – each additional 20 sq cm or less 11044 – Debridement, bone; first 20 sq cm or less • #+11047 – each additional 20 sq cm or less # indicates code out of sequence

10. New Guidelines Skin Replacement Surgery and Skin Substitutes • Clarification that these codes are used when there is a procedure for primary intention. • Debridement of wounds allowed to heal by secondary intention is to be coded with 97597-97598 or 11042-11047

11. Coding Clarifications • Primary intention – a procedure is to be performed for closure (immediately closed) • Secondary intention – the wound is to be allowed to heal “from the inside out”

12. Application • Skin substitute application codes are to be used when there is some sort of “fixation” • These codes are not to be used for simple graft application alone or application stabilized with dressings

13. Medicare on Skin Substitutes • 15340 and 15341 are to be used for Apligraf application • 15360, 15361, 15365, 15366 are to be used for Dermagraft application New G-codes (intended to be temporary) • G0440 – Application of tissue cultured allogeneic skin substitute or dermal substitute; for use on lower limb, includes site prep and debridement, first 25 sq cm or less • G0441 – each additional 25 sq cm

14. Sentinel Lymph Node Mapping • + 38900 – Intraoperative identification (eg, mapping) of sentinel lymph node(s), includes injection of non-radioactive dye Use existing code 38792 for injection of radioactive tracer (usually radiologists)

15. Musculoskeletal Procedures • CPT code 20000 deleted – incision of soft tissue abscess – use 10060/10061 • CPT code 20005 revised to indicate incision below deep fascia

16. Anterior Cervical Discectomy and Fusion Previously reported with – • 63075 – discectomy • 22554 – arthrodesis Codes were not deleted but can no longer be billed together • 22551 – Arthrodesis, anterior interbody, including preparation of disc space, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots • +22552 – each additional interspace

17. Arthroscopy of Hip – New Codes • 29914 – with femoroplasty • 29915 – with acetabuloplasty • 29916 – with labral repair • Parenthetical notes have been added after codes 29914 and 29915 instructing coders to not report the codes in conjunction with the other hip arthroscopy codes 29862 and 29863.

18. Otolaryngology New instructional and exclusion notes apply to all sinus endoscopy codes • 31295 – Nasal/sinus endoscopy, surgical; with dilation of maxillary sinus ostium • 31296 – with dilation of frontal sinus ostium • 31297 – with dilation of sphenoid sinus ostium These codes are for dilation without removal of tissue

19. Bronchoscopy • 31634 – with balloon occlusion, with assessment of air leak, with administration of occlusive substance, if performed • +0250T – airway sizing and insertion of bronchial valves, each lobe (use with 31622, 31634) • 0251T – Bronchoscopy with removal of bronchial valve(s), initial lobe • +0252T – each additional lobe

20. Cardiothoracic Surgery New Codes for Congenital Heart Surgery • 33620 – Application of R and L pulmonary artery bands (Hybrid stage 1) • 33621 – Transthoracic insertion of catheter for stent placement with catheter removal and closure (Hybrid stage 1) • 33622 – Reconstruction of complex cardiac anomaly (Hybrid stage 2)

21. Endovascular Revascularization • Bundles components into one code for treatment at any single level in the arterial tree – no distinction between open and percutaneous • Each code includes • Accessing and selectively catheterizing the vessel • Traversing the lesion • Embolic protection, if used • Completion imaging • Closure of the arteriotomy, by any method • Radiological supervision and interpretation

22. Territories – How Many Vessels? • Iliac – common iliac, internal iliac, external iliac • Femoral/popliteal – entire territory is considered a single vessel • Tibial/peroneal – anterior tibial, posterior tibial, peroneal

23. Endovascular Info • For same vessel, only one code is chosen • One base code is allowed in each territory • If bilateral, use modifier 59 • One lesion that spans two vessels but is treated with a single intervention is coded as one lesion • Report only the most comprehensive treatment in a given vessel – no more “intent rule” for failure of PTA

25. Diagnostic Angiography? Can be billed with modifier 59 if one of two criteria is met: • No prior catheter-based angiographic study is available, a full diagnostic study is performed, and the decision to intervene is based on this study • A prior study is available, but the patient’s condition has changed or there is inadequate visualization of the anatomy or there is a clinical change during the procedure that requires new evaluation outside the target area of the intervention

26. What is separately billable? With lower extremity endovascular intervention • Mechanical thrombectomy • Thrombolytic infusion • Ultrasound guidance for vascular access • Additional catheter access solely for diagnostic imaging purposes • Catheterization remains separately billable for category III supra-inguinal atherectomy

27. Example • Two lesions in the left common iliac vessel. The physician resolved one lesion in this vessel with angioplasty and the other lesion in the vessel was resolved by stent • The code is only 37221 • Only way to use an add-on code (37222, 37223) is IF the physician also provided separate service(s) in a different vessel on the SAME side, the internal iliac and/or external iliac

28. Example • Two lesions in the LEFT common iliac vessel. The physician resolved one lesion in this vessel with angioplasty and the other lesion in the vessel was resolved by stent. • The code is 37221 • In addition, there was a lesion in the RIGHT common iliac. Physician resolved this lesion by angioplasty. • The code is 37220 • Final coding for both: 37221-LT and 37220-RT • OR 37221 and 37220-59

29. Endovascular Revascularization • 66 year-old female with bilateral lower extremity claudication. Composite image of coronal oblique maximum intensity projections from a 3D gadolinium-enhanced MR angiogram exam demonstrates short segment stenoses of the RT (arrow) and LT(arrowhead) common iliac arteries. • http://www.rimed.org/medhealthri/2009-12/2009-12-398.pdf

30. Digestive System • 43324, 43326 deleted • 43327 – Esophagogastric fundoplasty partial or complete; laparotomy • 43328 - thoracotomy • +43338 – Esophageal lengthening procedure add-on code to be used with 43280, 43327-43337

31. Repair of Paraesophageal Hernia - (except neonatal) • 43332 – via laparotomy, without mesh • 43333 – via laparotomy, with mesh • 43334 – via thoracotomy, without mesh • 43335 – via thoracotomy, with mesh • 43336 – via thoracoabdominal incision, without mesh • 43337 – via thoracoabdominal incision, with mesh

32. Placement of Interstitial Devices Placement of interstitial device(s) for radiation therapy guidance, open, intra-abdominal, intrapelvic, and or retroperitoneum, including imaging guidance • +49327 – at time of laparoscopic procedure • +49412 – at time of open procedure

33. Placement of Tunneled Intraperitoneal Catheter • 49420 deleted – confusion with “permanent” and with procedures for drainage • 49418 – Insertion of tunneled intraperitoneal catheter, complete procedure, including imaging guidance, catheter placement, contrast injection and radiological S&I. • Dialysis • Intraperitoneal chemotherapy • Ascites management

34. Stereotactic Navigation Code changed to specify extradural vs. intradural vs. spinal – • +61782 – cranial, extradural Per AMA and AAO-HNS, not to be used on every sinus surgery –

35. Neurosurgery 61795 for stereotactic navigation deleted – new codes for specific locations • +61781 – cranial, intradural • +61782 – cranial, extradural (ENT–sinus surgery) • +61783 – spinal

36. Indications for Stereotactic Navigation • Revision sinus surgery • Distorted sinus anatomy of development, postoperative, or traumatic origin • Extensive sino-nasal polyposis • Pathology involving the frontal, posterior ethmoid and sphenoid sinuses • Disease abutting the skull base, orbit, optic nerve, or carotid artery • CSF rhinorrhea or conditions where there is a skull base defect • Benign and malignant sino-nasal neoplasms

37. Epidural Steroid Injections • 64479-64484 • Must be performed under CT or fluoro, but cannot bill imaging separately • If performed under ultrasound, use category III codes. Also be careful with 64415 (brachial plexus), 64445 (sciatic nerve), and 64447 (femoral nerve) – concern that providers are actually injecting the muscle rather than the nerve

38. Neurology Code Changes • 64566 – Posterior tibial neurostimulator, percutaneous needle electrode, single treatment, includes programming • 64611 – Chemodenervation of parotid and submandibular salivary glands, bilateral (Use modifier 52 if less than 4 glands injected)

39. Cranial Nerve Neurostimulator • 64568 – Incision for implantation of cranial nerve neurostimulator electrode array and pulse generator • 64569 – Revision or replacement of electrode array • 64570 – Removal of electrode array and pulse generator

40. Labyrinthotomy Δ 69801 – Labyrinthotomy, with perfusion of vestibuloactive drug(s); transcanal (previously billed once per treatment series, now once per day) Δ 69802 - with mastoidectomy (Rarely performed) Medicare will now pay separately for canalith repositioning (Epley maneuver).

41. Automated Audiometry • 0208T – pure tone audiometry (threshold), automated; air only • 0209T – air and bone • 0210T – Speech audiometry threshold, automated; • 0211T – with speech recognition • 0212T – Comprehensive audiometry threshold evaluation and speech recognition, automated If part auto and part manual, code each part separately

42. Ophthalmology • 65778 - Placement of amniotic membrane on the ocular surface for wound healing; self-retaining • 65779 – single layer, sutured Previous code 65780 now for multiple layers

43. Ophthalmology • 66174 – Transluminal dilation of aqueous outflow canal; without retention of device or stent • 66175 – with retention of device or stent Δ 66761 – Iridotomy/iridectomy by laser surgery, per session (previously one or more sessions)

44. Ophthalmology • 92132 – Scanning computerized ophthalmic diagnostic imaging, anterior segment, with interpretation and report , unilateral or bilateral • 92133 - Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report , unilateral or bilateral; optic nerve • 92134 - ….retina 92135 deleted.

45. Ophthalmology • 92227 – Remote imaging for detection of retinal disease with analysis and report under physician supervision, unilateral or bilateral • 92228 – Remote imaging for monitoring and management of retinal disease with physician review, interpretation and report, unilateral and bilateral

46. Radiology New codes for abdomen/pelvis CTs performed at the same session – • 74176 – CT, abdomen and pelvis, without contrast • 74177 - with contrast • 74178 - without then with contrast in one or both body regions Table, p. 369, CPT Professional

47. Ultrasound • 76881 – Ultrasound, extremity, nonvascular, real-time, complete • 76882 - limited, anatomic specific Complete ultrasound requires examination of a specific joint that includes examination of muscles, tendons, joint, other soft tissue structures, and any identifiable abnormality.

48. Pathology/Laboratory New Table p. 400 – CPT Professional • #80104 – Drug screen, qualitative; multiple drug classes other than chromatographic method, each procedure (equivalent to G0430)

49. Laboratory • 82930 – Gastric acid analysis • 83861 – Microfluidic analysis utilizing an integrated collection and analysis device, tear osmolarity • 84112 – Placental alpha microglobulin-1, cervicovaginal secretion, qualitative • 85598 – Phospholipid neutralization; hexagonal phospholipid • 86481 – Tuberculosis test, cell mediated immunity antigen response measurement; enumeration of interferon-producing T-cells in cell suspension

50. Laboratory • 86902 – Blood typing; antigen testing of donor blood using reagent serum; each antigen test • 87501 – Infectious agent detection by nucleic acid; influenza virus, reverse transcription and amplified probe technique • 87502 – influenza virus for multiple types or sub-types, reverse transcription and amplified probe technique, first 2 types or sub-types • 87503 - each additional beyond 2 • #87906 – Infectious agent genotype analysis by nucleic acid; HIV-1, other region