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2011 CPT Coding Updates. Sandy Giangreco, CCS, CPC, CPC-H, CPC-I, COBGC, PCS Compliance Audit Manager. CPT 2011. Always check for errata – http://www.ama-assn.org/ama1/pub/upload/mm/362/cpt-2011-corrections.pdf. Agenda for Session. Time-Based Coding Clarifications E/M Services

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2011 cpt coding updates

2011 CPT Coding Updates

Sandy Giangreco, CCS, CPC, CPC-H, CPC-I, COBGC, PCS

Compliance Audit Manager

cpt 2011
CPT 2011

Always check for errata –

http://www.ama-assn.org/ama1/pub/upload/mm/362/cpt-2011-corrections.pdf

agenda for session
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
time based coding clarifications
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
evaluation and management services
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
subsequent observation care
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
debridement
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
size matters
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.”

debridement1
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

new guidelines
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
coding clarifications
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”
application
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
medicare on skin substitutes
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
sentinel lymph node mapping
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)

musculoskeletal procedures
Musculoskeletal Procedures
  • CPT code 20000 deleted – incision of soft tissue abscess – use 10060/10061
  • CPT code 20005 revised to indicate incision below deep fascia
anterior cervical discectomy and fusion
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
arthroscopy of hip new codes
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.
otolaryngology
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

bronchoscopy
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
cardiothoracic surgery
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)
endovascular revascularization
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
territories how many vessels
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
endovascular info
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
diagnostic angiography
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
what is separately billable
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
example
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
example1
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
endovascular revascularization1
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
digestive system
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

repair of paraesophageal hernia except neonatal
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
placement of interstitial devices
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
placement of tunneled intraperitoneal catheter
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
stereotactic navigation
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 –

neurosurgery
Neurosurgery

61795 for stereotactic navigation deleted – new codes for specific locations

  • +61781 – cranial, intradural
  • +61782 – cranial, extradural (ENT–sinus surgery)
  • +61783 – spinal
indications for stereotactic navigation
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
epidural steroid injections
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

neurology code changes
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)

cranial nerve neurostimulator
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
labyrinthotomy
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).

automated audiometry
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

ophthalmology
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

ophthalmology1
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)

ophthalmology2
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.

ophthalmology3
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
radiology
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

ultrasound
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.

pathology laboratory
Pathology/Laboratory

New Table p. 400 – CPT Professional

  • #80104 – Drug screen, qualitative; multiple drug classes other than chromatographic method, each procedure

(equivalent to G0430)

laboratory
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
laboratory1
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
laboratory2
Laboratory
  • 88120 – Cytopathology, in situ hybridization, urinary tract specimen with morphometric analysis, 3-5 molecular probes, each specimen, manual
  • 88121 - computer-assisted
  • #88177 – Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy for diagnosis, each separate additional evaluation episode, same site
  • 88363 – Evaluation and selection of retrieved archival tissue(s) for molecular analysis
vaccine administration
Vaccine Administration

New codes for administration with counseling – for patients age 18 and under

  • 90460 – first vaccine/toxoid component
  • 90461 – each additional vaccine/toxoid component

All routes of administration

Use 90460 for each vaccine administered

52

example2
Example

2-month old infant receives the following immunizations according to schedule

DTaP – 90460, 90461, 90461, 90700

Rotavirus – 90460, 90681

Hepatitis B and HiB – 90460, 90461, 90748

Poliovirus – 90460, 90713

Pneumococcal vaccine – 90460, 90670

53

vaccines
Vaccines

Vaccines for Potential Future Pandemic

  • 90664 – intranasal administration
  • 90666 – preservative free, IM
  • 90667 – adjuvanted, IM
  • 90669 – IM administration

Hib-MenCY-TT

90644 – 4-dose schedule for children 2-15 mos

CHAN HEALTHCARE AUDITORS 54

gastroenterology
Gastroenterology
  • +91013 – Esophageal motility study with stimulation or perfusion during 2-dimensional data study
  • 91117 – Colon motility (manometric) study, minimum 6 hours continuous recording, with interpretation and report
gastroenterology1
Gastroenterology
  • 0226T – Anoscopy, high resolution, diagnostic, including collection of specimens by brushing or washing
  • 0227T - with biopsy
  • 0240T – Esophageal motility study with interpretation and report; with 3-dimensional high resolution esophageal pressure topography
  • +0241T - with stimulation or perfusion
  • 0242T – GI tract transit and pressure measurement, stomach through colon, wireless capsule, with interpretation and report
cardiology
Cardiology

Minor revisions to wording in Cardiovascular Monitoring Services –

  • Holter monitor now up to 48 hours
  • “Wearable” changed to “External”

MAJOR revisions to Cardiac Catheterization codes

  • Most non-congenital procedures will be reported with one code
  • Separate codes are retained for congenital heart catheterization (93530-93533)
heart cath changes1
Heart Cath Changes
  • Two Code Families: Congenital heart disease and all other conditions
  • Includes:
    • Introduction, positioning and repositioning of catheter
    • Recording of intracardiac and/or intravascular pressure
    • Evaluation and report
    • Contrast injection(s), imaging supervision, interpretation and report
    • Also all roadmapping angiography (including imaging supervision, interpretation and report
heart cath changes2
Heart Cath Changes
  • For LHC, left ventriculography is included
  • New add-on codes –
    • R heart injection procedures, supra valvular aortography, and pulmonary angiography
    • Coronary angiography, bypass angiography and L heart injection procedures only billable with congenital codes
    • L heart cath by transseptal or transapical puncture
    • Pharmacologic agent administration and exercise for assessing hemodynamic measurements
heart cath changes3
Heart Cath Changes
  • 93451 – R heart cath including measurements of O2 sat and cardiac output
  • 93452 – L heart cath including injection for L ventriculography, imaging supervision and interpretation, when performed
  • 93453 – R and L heart cath including injection for L ventriculography, imaging supervision and interpretation, when performed
heart cath changes4
Heart Cath Changes
  • 93454 – Cath placement in coronary arteries, including injection, imaging supervision and interpretation
  • 93455 - with cath placement in bypass grafts
  • 93456 - with R heart cath
  • 93457 - with cath placement in bypass grafts and R heart cath
  • 93458 - with L heart cath with ventriculography
heart cath changes5
Heart Cath Changes
  • 93459 - with L heart cath, L ventriculography, cath placement in bypass grafts with bypass graft angiography
  • 93460 - with R and L heart cath and L ventriculography
  • 93461 - with R and L heart cath, L ventriculography, cath placement in bypass grafts with bypass graft angiography
add on codes
Add-on Codes
  • +93462 – L heart cath by transseptal/ transapical puncture
    • Use in conjunction with 93452, 93453, 93458-93461, 93651, 93652
  • +93463 – Pharmacologic agent administration
    • Use only once per catheterization
  • +93464 – Physiologic exercise study
    • Use only once per catheterization
add on codes for injections
Add-on Codes for Injections

Only for use with congenital cath codes –

  • +93563 – selective coronary angiography
  • +93564 – bypass grafts
  • +93565 – L ventricle or L atrial angiography
  • +93566 - R ventricle or R atrial angiography
  • +93567 – supravalvular aortography
  • +93568 – pulmonary angiography
l heart cath coronary angiography l ventriculography
L heart cath, coronary angiography, L ventriculography

2010

93510

93543

93545

93555

93556

Work RVU: 6.65

2011

  • 93458

Work RVU: 5.85

acoustic cardiography
Acoustic Cardiography
  • 0223T – Acoustic cardiography… single, with interpretation and report
  • 0224T - multiple, AV or VV delays only, with interpretation and report
  • 0225T - multiple, AV and VV delays, with interpretation and report
noninvasive vascular studies
Noninvasive Vascular Studies

New guidelines for 93922 – 93924 –

93922-93923 – Requires 2 measurements –

  • in lower extremity, ABI at dorsalis pedis and posterior tibialis
  • in upper extremity, SBP in both arms

93924 – Measurements at rest and timed intervals – treadmill-specific

noninvasive vascular studies1
Noninvasive Vascular Studies

93922

  • One or two levels bilateral OR
  • 3+ levels unilateral

NOTE: one or two levels unilateral requires modifier 52

93923

  • Three or more levels bilateral OR
  • One or more levels bilateral with provocative functional maneuvers

93924 – Standardized protocol on a motorized treadmill plus recording of time of onset of claudication, maximal walking time, time to recovery in both legs – no alternate exercise

unattended sleep studies
Unattended Sleep Studies
  • 95800 – Sleep study, unattended, simultaneous recording; heart rate, oxygen saturation, respiratory analysis, and sleep time
  • 95801 – Sleep study, unattended, simultaneous recording; minimum of heart rate, oxygen saturation, and respiratory analysis
annual wellness visit
Annual Wellness Visit
  • For every Medicare patient
    • 12 months after effective date of Medicare
    • Has not received an IPPE (“Welcome to Medicare”) in past 12 months

71

awv requirements
AWV Requirements

Health Risk Assessment and creation of a Personalized Prevention Plan

  • Establish or update an individual medical and family history
  • List of current providers and supplies and medications prescribed for the individual
  • Measurement of height, weight, BMI or waist circumference, blood pressure

72

awv requirements1
AWV Requirements
  • Detection of any cognitive impairment
  • Establish or update an appropriate screening schedule for the next 5-10 years
  • Voluntary advance care planning
  • Establish or update list of risk factors and condition (including mental health condition)
  • Personalized health advice and referral to health education or prevention counseling services or programs
  • Depression screening and functional status at 1st annual wellness visit only

73

awv codes
AWV Codes
  • G0438 – first visit (not new patient, but first wellness visit)
  • G0439 – subsequent visit
  • G0438 paid at same rate as 99204

G0439 paid at same rate as 99214

  • Can bill separately identifiable E&M same day with modifier 25.
  • Not subject to “incident-to” - but may be performed by a team of professionals under the direct supervision of the billing physician

74

removal of barriers to preventive services
Removal of Barriers to Preventive Services
  • Medicare can add additional preventive services identified by the US Preventive Services Task Force
  • Waives deductible and coinsurance for services rated grade A or B

http://www.uspreventiveservicestaskforce.org/

75

resources
Resources
  • Kim Gardner Huey, CPC, CCS-P, CHCC, PCS, CHAP
  • 2011 CPT Professional Edition
  • 2011 CPT AMA Symposium
  • Physicians First “2011 Endovascular Revascularization (Open or Percutaneous,Transcatheter)”
  • Maine Health “2011 CPT Changes Overview”
thank you

Thank You!

Sandy Giangreco, CCS, CPC, CPC-H, CPC-I, COBGC, PCS

[email protected]

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