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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 changes

    Heart Cath Changes


    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”


    Questions

    Questions?


    Thank you

    Thank You!

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

    [email protected]

    78


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