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CPT Code Changes 2015 2015 OIG Updates Catherine Gray, RHIT, CPC, CPC-H CCC, CEMC, CGIC

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Presentation on theme: "CPT Code Changes 2015 2015 OIG Updates Catherine Gray, RHIT, CPC, CPC-H CCC, CEMC, CGIC"— Presentation transcript:

1 CPT Code Changes OIG Updates Catherine Gray, RHIT, CPC, CPC-H CCC, CEMC, CGIC

2 CPT® Disclaimer CPT copyright 2015 American Medical Association. All rights reserved. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. CPT is a registered trademark of the American Medical Association

3 Highlights for Hospitals, Physicians and Health Plans 2014 OIG Work Plan

4 2015 OIG Work Plan O The HHS Office of Inspector General (OIG) Work Plan for Fiscal Year 2015 summarizes new and ongoing reviews and activities that OIG plans to pursue with respect to HHS programs and operations during the current fiscal year and beyond. O The Work Plan describes the primary objectives and provides for each review its internal identification code and the year in which we expect one or more reports to be issued as a result of the review. O When reports are issued, they are posted to OIG's website. OIG's list subscribers automatically receive notification when new reports are posted to the website.

5 2015 OIG Work Plan O New Inpatient Admission Criteria O We will determine the impact of new inpatient admission criteria on hospital billing, Medicare payments, and beneficiary copayments. O Previous OIG work identified millions of dollars in overpayments to hospitals for short inpatient stays that should have been billed as outpatient stays. O Beginning in FY 2014, new criteria state that physicians should admit for inpatient care those beneficiaries who are expected to need at least 2 nights of hospital care (known as the “two midnight policy”). O Beneficiaries whose care is expected to last fewer than 2 nights should be treated as outpatients. The criteria represent a substantial change in the way hospitals bill for inpatient and outpatient stays.

6 2015 OIG Work Plan O Medicare Costs Associated with Defective Medical Devices O We will review Medicare claims to identify the costs resulting from additional use of medical services associated with defective medical devices and determine the impact of the cost on the Medicare Trust Fund. O CMS has previously expressed concerns about the impact of the cost of replacement devices, including ancillary cost, on Medicare payments for inpatient and outpatient services.

7 2015 OIG Work Plan O Medicare Oversight of Provider-based Status O We will determine the extent to which provider- based facilities meet CMS’s criteria. O Provider-based status allows facilities owned and operated by hospitals to bill as hospital outpatient departments. (POS 15 vs 22) O Provider-based status can result in higher Medicare payments for services furnished at provider-based facilities and may increase beneficiaries’ coinsurance liabilities.

8 2015 OIG Work Plan O Comparison of Provider-based and Free-standing Clinics O We will review and compare Medicare payments for physician office visits in provider-based clinics and free-standing clinics to determine the difference in payments made to the clinics for similar procedures and assess the potential impact on the Medicare program of hospitals' claiming provider based status for such facilities. O Provider-based facilities often receive higher payments for some services than do freestanding clinics.

9 2015 OIG Work Plan O Inpatient Claims for Mechanical Ventilation O We will review Medicare payments for inpatient hospital claims with certain MS-DRG assignments that require mechanical ventilation to determine whether hospitals’ DRG assignments and resultant Medicare payments were appropriate. O Mechanical ventilation is the use of a ventilator or respirator to take over active breathing for a patient. Claims must be completed accurately to be processed correctly and promptly. O For certain DRGs to qualify for Medicare coverage, a patient must receive 96 or more hours of mechanical ventilation. Our review will include claims for beneficiaries who received over 96 hours of mechanical ventilation. Previous OIG reviews identified improper payments made because hospitals inappropriately billed for beneficiaries who did not receive 96 or more hours of mechanical ventilation.

10 2015 OIG Work Plan O Outpatient E/M Services Billed at the New-patient Rate (G0463) O We will review Medicare outpatient payments made to hospitals for evaluation and management (E/M) services for clinic visits billed at the new-patient rate to determine whether they were appropriate and will recommend recovery of overpayments. O Preliminary work identified overpayments that occurred because hospitals used new-patient codes when billing for services to established patients. O The rate at which Medicare pays for E/M services requires hospitals to identify patients as either new or established, depending on previous encounters with the hospital. O According to Federal regulations, the meaning of “new” and “established” pertains to whether the patient has been seen as a registered inpatient or outpatient of the hospital within the past 3 years.

11 2015 OIG Work Plan O Nationwide Review of Cardiac Caths and Endomyocardial Biopsies O We will review Medicare payments for right heart catheterizations (RHC) and endomyocardial biopsies billed during the same operative session and determine whether hospitals complied with Medicare billing requirements. O Previous OIG reviews have identified inappropriate payments when hospitals were paid for separate RHC procedures when the services were already included in payments for endomyocardial biopsies. To be processed correctly and promptly, a bill must be completed accurately.

12 2015 OIG Work Plan O Risk adjustment data—Sufficiency of documentation supporting diagnoses O We will review the medical record documentation to ensure that it supports the diagnoses MA organizations submitted to CMS for use in CMS’s risk-score calculations and determine whether the diagnoses submitted complied with Federal requirements. O Prior OIG reviews have shown that medical record documentation does not always support the diagnoses submitted to CMS by MA organizations. O MA organizations are required to submit risk adjustment data to CMS in accordance with CMS instructions. O Payments to MA organizations are adjusted on the basis of the health status of each beneficiary, so inaccurate diagnoses may cause CMS to pay MA organizations improper amounts.

13 2013 OIG Posted Audit Results Results have been posted to the OIG website for six Medicare Advantage Organizations General Findings: O The MAO did not have written policies and procedures for obtaining, processing, and submitting diagnoses to CMS. O Practices were not effective in ensuring that the diagnoses MAO submitted to CMS complied with the requirements of the Risk Adjustment Participant Guide.

14 2013 OIG Posted Audit Results Results have been posted to the OIG website for 6 Medicare Advantage Organizations Coding/Claims specific issues O Documentation did not support the claimed diagnosis. O Documentation did not include the provider’s signature or credentials. O No documentation was offered to support diagnosis. O Unconfirmed diagnoses

15 2013 OIG Posted Audit Results Results have been posted to the OIG website for 6 Medicare Advantage Organizations Coding/Claims specific issues O No documentation that diagnosis affected the care, treatment, or management provided during the encounter. O Taking diagnosis codes from problem lists or other documentation that merely lists diagnoses with no indication of evaluation and treatment for each condition. O Taking diagnoses from patient histories or history codes. O Claiming a diagnosis code based solely on prescription medication.

16 2013 OIG Posted Audit Results O Audit Scrutiny of Medicare Risk Adjustment Payments- (extrapolated) O PacifiCare of Texas- $115,422,084 (43% not validated) O O Excellus Health Plan- $41,588,811 (46% coding not validated) O https://oig.hhs.gov/oas/reports/region2/ pdf https://oig.hhs.gov/oas/reports/region2/ pdf O Pacific Care of California- $423,709,068- (45% not validated) O https://oig.hhs.gov/oas/reports/region9/ pdf https://oig.hhs.gov/oas/reports/region9/ pdf

17 2013 OIG Posted Audit Results O Audit Scrutiny of Medicare Risk Adjustment Payments- (extrapolated) O Paramount Care (Promedica)- $18,216,541 (44% not validated) O https://oig.hhs.gov/oas/reports/region5/ pdf https://oig.hhs.gov/oas/reports/region5/ pdf O Bravo Health Pennsylvania- $22,108,905 (65% not validated) O https://oig.hhs.gov/oas/reports/region3/ pdf https://oig.hhs.gov/oas/reports/region3/ pdf O Cigna Healthcare of Arizona- $28,353,516 (40% not validated) O https://oig.hhs.gov/oas/reports/region7/ pdf https://oig.hhs.gov/oas/reports/region7/ pdf

18 Modifiers, G codes, Anesthesia, Global Surgery Concepts 2015 OPPS Update

19 CMS- Modifier 59 O Previous OIG Report on Modifier 59 O On August 15, 2014 CMS released the final ruling for appropriate Modifier 59 use. (Transmittal 1422, CR8863) O The changes will take effect on January 1, O These modifiers, are referred to as X-EPSU modifiers, and define specific subsets of the -59 modifier. O CMS will not stop recognizing the -59 modifier but notes that CPT instructions state that the -59 modifier should not be used when a more descriptive modifier is available..

20 CMS- Modifier 59 O Transmittal 1422, CR8863 details new modifiers to be used in place of modifier 59. The new modifiers will impact NCCI (National Correct Coding Initiative) edits utilized by CMS MAC Carriers. O XE Separate Encounter: Service That Is Distinct Because It Occurred During A Separate Encounter O XP Separate Practitioner: Service That Is Distinct Because It Was Performed By A Different Practitioner O XS Separate Structure: Service That Is Distinct Because It Was Performed On A Separate Organ/Structure O XU Unusual Non-Overlapping Svc: Use Of A Service That Is Distinct Because It Does Not Overlap usual components of the main service

21 CMS- Modifier 59 O The new modifiers are to be used in place of modifier 59. They will impact NCCI (National Correct Coding Initiative) edits utilized by CMS MAC Carriers. O Studies have shown that the modifier 59 is both commonly used and commonly abused. O According to the 2013 CERT report $2.4 billion was paid on claims containing modifier 59 with a projected error rate of $450 million. O The error rate is not exclusively attributed to modifier 59, but if only 10% of those found to be in error were due to the modifier 59, that would represent a $45 million damage. O No word on recognition of these modifiers by other payers.

22 CMS- Updates O G codes for new CPT codes- If the new CPT codes are unavailable at the time the OPPS final rule is published, CMS will be issuing G codes for these services and they will be valued accordingly. O The 2015 rates of the created G codes will be based on the comparable 2014 CPT codes.

23 CMS- Updates O Anesthesia for Screening Colonoscopies- in the past moderate sedation was included in endoscopy services. O Anesthesia is now being used more frequently with these services. O For 2015, all anesthesia will be included in screening colonoscopy codes. O This will result in coinsurance and deductible being waived for the patient. O Anesthesiologist should bill with -33 to show it is for screening service.

24 CMS- Updates O Global Surgery- Transforming all 10 day and 90 day global periods into 0 day global periods. Goal is: O 10 day in CY 2017 O 90 day in CY 2018 O Goal is to value all services appropriately taking into consideration each component, pre-operative, intra-operative and post- operative components.

25 2015 CPT Changes All Rights Reserved 2012

26 2015 CPT Changes O 542 Total Code Changes O 266 New Codes O 147 Deleted Codes O 129 Revised Codes O Guideline Changes

27 Evaluation and Management

28 Evaluation and Management O Evaluation and Management Workgroup O Created in response from AMA members regarding increased use of templates and EMRs creating over documentation and inflation of E/M services. O Define the importance of making MDM a required key component in determining E/M code O Determined to be a more substantial change than anticipated. O Unable to be implemented at this time, assigning appropriate values O Work tabled for use in the future.

29 Evaluation and Management O Social History- The social history element of history documentation in the E/M guidelines has been revised to include any history of military service. The addition of this element will assist with diagnosing, assessing, and treating service members, veterans and their families.

30 Evaluation and Management O Deleted Total body systemic hypothermia in a critically ill neonate per day O Deleted Selective head hypothermia in a critically ill neonate per day O New Code (in the medicine section) Initiation of selective head or total body hypothermia in the critically ill neonate, includes appropriate patient selection by review of clinical, imaging and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitude EEG, supervision of controlled hypothermia, and assessment of patient tolerance of cooling

31 Evaluation and Management O Care Management Services- Guidelines clarified O Chronic Care Management Services O Complex Chronic Care Management Services O Transitional Care Management Services O Advanced Care Planning

32 Evaluation and Management O Chronic Care Management Services (Revised Code)- O Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient; chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; comprehensive care plan established, implemented, revised, or monitored O CCMS of less than 20 minutes duration are not reported separately.

33 Evaluation and Management O Maternity Care and Delivery Guidelines Clarifications O The services normally provided in uncomplicated maternity cases include antepartum care, delivery and postpartum care. Pregnancy confirmation during a problem oriented or preventive visit is not considered a part of antepartum care and should be reported using the appropriate E/M service code for that visit.

34 Anesthesia

35 Anesthesia O Codes deleted due to low utilization: O Anesthesia for procedures on clavicle and scapula; radical surgery O Anesthesia for procedures on thoracic cord and spine; thoracolumbar sympathectomy O Anesthesia for procedures in lumbar region; lumbar sympathectomy

36 General Surgery Surgery Guidelines

37 General Surgery O CPT Surgical Package Definition- By their very nature, the services to any patient are variable. The CPT codes that represent a readily identifiable surgical procedure thereby include, a variety of services. The following services related to the surgery when furnished by the physician or other qualified health care professional who performs the surgery are included: O E/M services subsequent to the decision for surgery on the day before and/or day of surgery (including H&P) O Local infiltration, digital block or topical anesthesia O Immediate PO care including dictation of operative note, talking with family and other physicians O Writing orders O Evaluating the patient in the recovery area O Typical postoperative follow up care O Addresses inclusive E/M services, clarifies who can perform services, clarifies what services are included.

38 Integumentary No Changes for 2015!!

39 Musculoskeletal

40 Musculoskeletal O Joint Procedures O The existing code series was updated to indicate with/without Ultrasound guidance O Arthrocentesis, aspiration and/or injection; small joint or bursa (eg, fingers, toes); without ultrasound guidance O Arthrocentesis, aspiration and/or injection, small joint or bursa (eg, fingers, toes); with ultrasound guidance, with permanent recording and reporting O Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); without ultrasound guidance O Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); with ultrasound guidance, with permanent recording and reporting

41 Musculoskeletal O Joint Procedures O Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance O Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting O Parenthetical notes restricts use of with these codes. O If Flouroscopic, MRI or CT guidance used, report codes 20600, or for the procedure, and then code guidance 77002, 77012,

42 Musculoskeletal O Ablation Therapy O The existing code for radiofrequency bone ablation has been updated to include adjacent soft tissue and radiologic guidance. In addition, a new code has been added for cryoablation of bone tumors. O Ablation therapy for reduction or eradication of 1 or more bone tumors (eg, metastasis), including adjacent soft tissue when involved by tumor extension, percutaneous, including imaging guidance when performed; radiofrequency O cryoablation

43 Musculoskeletal O Vertebroplasty/Kyphoplasty O The existing codes have been deleted and new codes have been created to include all imaging guidance. It was found imaging guidance was used 75% of the time. O Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; cervicothoracic O lumbosacral O each additional cervicothoracic or lumbosacral vertebral body (List separately in addition to code for primary procedure)

44 Musculoskeletal O Vertebroplasty/Kyphoplasty- cont O Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; thoracic O lumbar O each additional thoracic or lumbar vertebral body (List separately in addition to code for primary procedure) O Current codes 22520, 22521, 22522, 22523, 22524, 22525, and have been deleted

45 Musculoskeletal Vertebroplasty Kyphoplasty

46 Musculoskeletal O Sacroplasty O Sacroplasty did not yet receive a new code, but the existing Category III code has been revised to include all imaging guidance. O 0200T Percutaneous sacral augmentation (sacroplasty), unilateral injection(s), including the use of a balloon or mechanical device, when used, 1 or more needles, includes imaging guidance and bone biopsy, when performed O 0201T Percutaneous sacral augmentation (sacroplasty), unilateral injection(s), including the use of a balloon or mechanical device, when used, 2 or more needles, includes imaging guidance and bone biopsy, when performed

47 Musculoskeletal O Open Treatment of Rib Fractures O 21800, 21810, 0245T, 0246T, 0247T, 0248T have been deleted O Open treatment of rib fracture(s) with internal fixation, includes thoracoscopic visualization when performed, unilateral; 1-3 ribs O ribs O or more ribs O Codes selected based on the number of ribs treated

48 Musculoskeletal O Total Disc Arthroplasty O Revised to be the parent code for O Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection), single interspace, cervical O second level, cervical (List separately in addition to code for primary procedure) O 0375T- cervical, three or more levels

49 Musculoskeletal

50 O Arthrodesis of Sacroiliac Joint O Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixing device O Arthrodesis, sacroiliac joint (including obtaining graft), open O Codes are unilateral, use -50 if bilateral

51 Respiratory

52 Respiratory O Ablation Pulmonary Tumors O A Category III code has been created for cryoablation of pulmonary tumors. O 0340T- Ablation, pulmonary tumor(s), including pleura or chest wall when involved by tumor extension, percutaneous, cryoablation, unilateral, includes imaging guidance

53 Respiratory

54 Cardiovascular

55 Cardiovascular O Subcutaneous Pacemaker or Implantable Defibrillator O Category III codes 0319T, 0320T, 0321T, 0322T, 0323T, 0324T, 0326T, 0327T have been deleted and replaced with Category I codes. O Revisions have been made to the established codes, guidelines and the table has been updated with the new codes

56 Cardiovascular O Subcutaneous Pacemaker or Implantable Defibrillator O Insertion or replacement of permanent subcutaneous implantable defibrillator system, with subcutaneous electrode, including defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters, when performed

57 Cardiovascular O Subcutaneous Pacemaker or Implantable Defibrillator O Insertion of subcutaneous implantable defibrillator electrode O Removal of subcutaneous implantable defibrillator electrode O Repositioning of previously implanted subcutaneous implantable defibrillator electrode

58 Cardiovascular O Transcatheter Mitral Valve Repair O Category III codes 0343T and 0344T have been deleted and replaced with Category I codes. O Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; initial prosthesis O additional prosthesis(es) during same session (List separately in addition to code for primary procedure) O 0345T- Transcatheter mitral valve repair percutaneous approach via the coronary sinus

59 Cardiovascular

60 O Extracorporeal Membrane Oxygenation (ECMO) O 33960, 33961, have been deleted O New category and guidelines created O New codes include: Initiation of ECMO, daily management, cannulation, repositioning, adding, removing of cannula

61 Cardiovascular

62 O Extracorporeal Membrane Oxygenation (ECMO) O Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; initiation, veno-venous O initiation, veno-arterial O daily management, each day, veno-venous O daily management, each day, veno-arterial

63 Cardiovascular O Extracorporeal Membrane Oxygenation (ECMO) O Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; insertion of peripheral (arterial and/or venous) cannula(e), percutaneous, birth through 5 years of age (includes fluoroscopic guidance, when performed) O years or older O open, birth-5 years O open, 6 years or older

64 Cardiovascular O Extracorporeal Membrane Oxygenation (ECMO) O insertion of central cannula(e) by sternotomy or thoracotomy, birth through 5 years of age O years or older O reposition peripheral (arterial and/or venous) cannula(e), percutaneous, birth through 5 years of age (includes fluoroscopic guidance, when performed) O years or older

65 Cardiovascular O Extracorporeal Membrane Oxygenation (ECMO) O reposition peripheral (arterial and/or venous) cannula(e), open, birth through 5 years of age (includes fluoroscopic guidance, when performed) O years or older O by sternotomy or thoracotomy, birth through 5 years of age O years or older

66 Cardiovascular O Extracorporeal Membrane Oxygenation (ECMO) O removal peripheral (arterial and/or venous) cannula(e), percutaneous, birth through 5 years of age (includes fluoroscopic guidance, when performed) O years or older O open, birth-5 years of age O open, 6 years or older

67 Cardiovascular O Extracorporeal Membrane Oxygenation (ECMO) O removal peripheral (arterial and/or venous) cannula(e), by sternotomy or thoracotomy, birth through 5 years of age (includes fluoroscopic guidance, when performed) O years or older

68 Cardiovascular O Transcatheter Placement of Intravascular Stents O A multispecialty society request was made to establish a new code to report the transcatheter placement of an intrathoracic carotid vascular stent. O Editorial revision of cervical carotid artery stent codes and codes 0075T-0076T also was requested to differentiate these codes from the new code and to make them consistent with all other endovascular bundled coding.

69 Cardiovascular O Transcatheter Placement of Intravascular Stents O Existing codes for carotid stent placement have been revised to include angioplasty and radiologic supervision and interpretation. These codes should also be used for open or percutaneous approach, which is a change for O Transcatheter placement of intravascular stent(s), cervical carotid artery, open or percutaneous, including angioplasty, when performed, and radiological supervision and interpretation; with distal embolic protection O without distal embolic protection

70 Cardiovascular O Transcatheter Placement of Intravascular Stents O Transcatheter placement of an intravascular stent(s), intrathoracic common carotid artery or innominate artery by retrograde treatment, via open ipsilateral cervical carotid artery exposure, including angioplasty, when performed, and radiological supervision and interpretation

71 Cardiovascular O Transcatheter Placement of Intravascular Stents O Previously a Category III code, there is now a CPT code for placement of intrathoracic common carotid or innominate artery stent. This code includes angioplasty and imaging. O Transcatheter placement of intravascular stent(s), intrathoracic common carotid artery or innominate artery, open or percutaneous antegrade approach, including angioplasty, when performed, and radiological supervision and interpretation

72 Cardiovascular O Transcatheter Placement of Intravascular Stents O 0075T- Transcatheter placement of extracranial vertebral or intrathoracic carotid artery stent(s), including radiologic supervision and interpretation, percutaneous; initial vessel O 0076T- each additional vessel

73 Digestive

74 Digestive O Esophagoscopy O 1 new code, 6 revised codes O Esophagoscopy, rigid, transoral with diverticulectomy of hypopharynx or cervical esophagus (eg, Zenker's diverticulum), with cricopharyngeal myotomy, includes use of telescope or operating microscope and repair, when performed O Esophagoscopy, rigid, transoral; with removal of foreign body O Esophagoscopy, flexible, transnasal; diagnostic, includes collection of specimen(s) by brushing or washing when performed (separate procedure)

75 Digestive O Esophagoscopy O Esophagoscopy, flexible, transoral; with removal of foreign body O with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery O with removal of tumor(s), polyp(s), or other lesion(s) by snare technique O with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery O was deleted

76 Digestive O Endoscopy O Parent codes 44360, 44376, 44380, 44385, 44388, and are now designated as separate procedures. O Editorial change to: “including collection of specimens by brushing or washing, when performed” replaces “with or without collection of specimens” for consistency with other codes. O Control of bleeding instruction: Control of bleeding that occurs as a result of the endoscopic procedure is not separately reportable during the same operative session O Further Clarification of modifiers 52 and 53

77 Digestive O Endoscopy, Small Intestine O Divided into two separate subcategories: Endoscopy, Small Intestine and Endoscopy, Stomal O New Section Guidelines have been added O Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) O with removal of foreign body

78 Digestive O Endoscopy, Stomal O Ileoscopy, through stoma; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) O with transendoscopic balloon dilation O with biopsy, single or multiple O deleted O with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed)

79 Digestive O Endoscopy, Stomal O Endoscopic evaluation of small intestinal (abdominal or pelvic) pouch; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) O with biopsy, single or multiple

80 Digestive

81 O Endoscopy Stomal (Colon)- revised O Colonoscopy through stoma; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) O with removal of foreign body O with control of bleeding, any method O with removal of tumors, polyps or other lesions by hot biopsy forceps

82 Digestive O Endoscopy Stomal (Colon)- new O Colonoscopy through stoma; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre-and post-dilation and guide wire passage, when performed) O with endoscopic stent placement (including pre- and post-dilation and guide wire passage, when performed) O with endoscopic mucosal resection O with directed submucosal injection(s), any substance

83 Digestive O Endoscopy Stomal (Colon)- new O Colonoscopy through stoma; with transendoscopic balloon dilation O with endoscopic ultrasound examination, limited to the sigmoid, descending, transverse, or ascending colon and cecum and adjacent structures O with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s), includes endoscopic ultrasound examination limited to the sigmoid, descending, transverse, or ascending colon and cecum and adjacent structures O with decompression (for pathologic distention) (eg, volvulus, megacolon), including placement of decompression tube, when performed

84 Digestive

85 O Endoscopy- Sigmoidoscopy O Sigmoidoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed) O with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed) O with endoscopic mucosal resection O with band ligation(s) (eg, hemorrhoids)

86 Digestive O Endoscopy- Colonoscopy O Colonoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post- dilation and guide wire passage, when performed) O with endoscopic stent placement (includes pre- and post-dilation and guide wire passage, when performed) O with endoscopic mucosal resection O with decompression (for pathologic distention) (eg, volvulus, megacolon), including placement of decompression tube, when performed O with band ligation(s) (eg, hemorrhoids)

87 Digestive O Endoscopy- Anus O Anoscopy; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)(revised) O 0226T and 0227T have been deleted O Anoscopy; diagnostic, with high- resolution magnification (HRA) (eg, colposcope, operating microscope) and chemical agent enhancement, including collection of specimen(s) by brushing or washing, when performed O with biopsy, single or multiple

88 Digestive O Colonoscopy and Modifier 52 O For therapeutic examinations that do not reach the cecum, report the appropriate therapeutic colonoscopy code with modifier 52 with appropriate documentation. O Report flexible sigmoidoscopy ( ) for endoscopic examination during which the endoscope is not advanced beyond the splenic flexure.

89 Digestive O Colonoscopy and Modifier 53 O When performing a screening or diagnostic endoscopy on a patient who is scheduled and prepared for a total colonoscopy, if the physician is unable to advance the colonoscope to the cecum or colon-small intestine anastomosis due to unforeseen circumstances, report with modifier 53 with appropriate documentation.

90 Urinary

91 Urinary O 2 new Cystoscopy codes O Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; single implant O each additional permanent adjustable transprostatic implant (List separately in addition to code for primary procedure)

92 Nervous System

93 60000 Neurological O Myelography O New myelography codes were created which include the supervision and interpretation. The existing code for myelogram injection has been revised and 4 new codes have been added O Injection procedure for myelography and/or computed tomography, spinal lumbar (other than C1-C2 and posterior fossa) O Myelography via lumbar injection, including radiological supervision and interpretation; cervical O thoracic O lumbosacral O or more regions (eg, lumbar/thoracic, cervical/thoracic, lumbar/cervical, lumbar/thoracic/cervical)

94 Radiology

95 Radiology O Breast Imaging O New codes have been introduced for breast tomosynthesis. Also, the existing code for breast ultrasound was deleted and two new codes have been introduced for limited and complete ultrasound. O Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete O Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; limited O Digital breast tomosynthesis; unilateral O Digital breast tomosynthesis; bilateral O Screening digital breast tomosynthesis, bilateral (List separately in addition to code for primary procedure) (77057) O has been deleted

96 Radiology

97 O Vertebral Fracture Assessment O The existing code for vertebral fracture assessment (VFA) has been deleted and 2 new codes have been introduced for One code represents VFA done as part of a bone density study and the other is for VFA alone.. O Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine), including vertebral fracture assessment O Vertebral fracture assessment via dual- energy X-ray absorptiometry (DXA) O was deleted

98 Radiology O New Category III* codes have been introduced for radiostereometric analysis. O 0348T Radiologic examination, radiostereometric analysis (RSA); spine, (includes cervical, thoracic and lumbosacral, when performed) O 0349T Radiologic examination, radiostereometric analysis (RSA); upper extremity(ies), (includes shoulder, elbow, and wrist, when performed) O 0350T Radiologic examination, radiostereometric analysis (RSA); lower extremity(ies), (includes hip, proximal femur, knee, and ankle, when performed)

99 Radiation Oncology

100 Radiation Oncology O Radiation Therapy O Radiation therapy codes underwent significant changes for Teletherapy isodose planning and brachytherapy codes now include the basic dosimetry calculation and IMRT codes now include guidance and tracking. Also radiation treatment delivery codes were deleted in O Teletherapy isodose plan; simple (1 or 2 unmodified ports directed to a single area of interest), includes basic dosimetry calculation(s) O Teletherapy isodose plan; complex (multiple treatment areas, tangential ports, the use of wedges, blocking, rotational beam, or special beam considerations), includes basic dosimetry calculation(s) O Brachytherapy isodose plan; simple (calculation[s] made from 1 to 4 sources, or remote afterloading brachytherapy, 1 channel), includes basic dosimetry calculation(s) O 77305, 77310, 77315, 77326, 77327, have been deleted

101 Radiation Oncology O Radiation Therapy O Brachytherapy isodose plan; intermediate (calculation[s] made from 5 to 10 sources, or remote afterloading brachytherapy, 2-12 channels), includes basic dosimetry calculation(s) O Brachytherapy isodose plan; complex (calculation[s] made from over 10 sources, or remote afterloading brachytherapy, over 12 channels), includes basic dosimetry calculation(s) O Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when performed; simple O Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when performed; complex O Guidance for localization of target volume for delivery of radiation treatment delivery, includes intrafraction tracking, when performed

102 Pathology and Laboratory

103 Pathology and Laboratory O The new section in the AMA book includes the addition of guidelines, parentheticals, and tables that are used to direct reporting within the 2 new subsections. O The codes included within these subsections identify drug procedures according to the purpose of the procedure and type of patient results obtained. O The Presumptive Drug Class Screening section includes Guidelines for the Presumptive Drug Class Screening section, Drug Class List A (which itemizes commonly assayed drugs within the listing), and Drug Class List B (which itemizes assays that require more resources than Class A). O This section also includes guidelines that explain the intended use for the listing and the codes.

104 Pathology and Laboratory O The updated reporting mechanism has been designed to address the following: O ability to be easily modified for future changes and technological advances O identification of updated clinical settings O identification of “sources” for specimen(s).

105 Pathology and Laboratory O Microbiology Changes O Along with several other changes, codes 87623, 87624, have been added to report human papilloma virus (HPV) genotyping to differentiate high and low risk HPV types. O HPV genotyping is used in conjunction with or as follow-up to an abnormal cytology report. O The existing HPV codes 87620, and have been deleted and replaced with genotyping codes that describe the specific types test

106 Pathology and Laboratory O Surgical Pathology Changes O Immunocytochemistry and immunohistochemistry CPT codes have undergone additional changes for O The histomorphometry codes 88360, for reporting detection of protein receptors for diagnosing the development of tumor(s) and cancer have been revised. O The in situ hybridization codes 88365, 88367, have been revised and expanded into three separate families of codes that identify; O 1) the initial single probe stain procedure (88365, 88367, 88368) O 2) each additional single probe stain procedure (88364, 88373, 88369) O 3) each multiplex probe stain procedure (88366, 88374, 88377

107 Medicine

108 Medicine O Vaccines O Human Papillomavirus vaccine types 6, 11, 16, 18, 31, 33, 45, 52, 58, nonavalent (HPV), 3 dose schedule, for intramuscular use O Influenza virus vaccine, split virus, preservative-free, for intradermal use O Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, for intradermal use O Diphtheria, tetanus toxoids, and acellular pertussis vaccine and Hemophilus influenza B vaccine (DTaP-Hib), for intramuscular use O Diphtheria, tetanus toxoids, acellular pertussis vaccine, Hepatitis B, and poliovirus vaccine, inactivated (DTaP- HepB-IPV), for intramuscular use O Meningococcal conjugate vaccine, serogroups A, C, Y and W-135 (tetravalent), for intramuscular use

109 Medicine O 92541: Spontaneous nystagmus test, including gaze and fixation nystagmus, with recording O 92542: Positional nystagmus test, minimum of 4 positions, with recording O 92543: Caloric vestibular test, each irrigation (binaural, bithermal stimulation constitutes 4 tests), with recording O 92544: Optokinetic nystagmus test, bidirectional, foveal or peripheral stimulation, with recording O 92545: Oscillating tracking test, with recording

110 Medicine O Negative pressure wound therapy, (eg, vacuum assisted drainage collection), utilizing disposable, non-durable medical equipment including provision of exudate management collection system, topical application(s), wound assessment, and instructions for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters O total wound(s) surface area greater than 50 square centimeters

111 Medicine O Application of topical fluoride varnish by a physician or other qualified health care professional


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