1. 2020 CPT Changes: Marsha S. Diamond, CPC, COC, CCS, CPMA, AAPC Fellow
01/21/20
Greater Orlando AAPC Chapter

2. TODAY’S AGENDA E/M Changes 2020 and Beyond Surgery Updates
Radiology Updates
Pathology Updates
Medicine Updates
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3. 2020 E/M CPT Changes: CPT Has Entered the Digital Age!

4. NEW CODES FOR ONLINE DIGITAL E/M
Deletion of and replacement with the following more specific codes:
99421 Online digital evaluation and management service, EP, for up to 7 days cumulative time during the 7 days; minutes
minutes
or more minutes
Must be type that would be done face-to-face
Performed through HIPAA compliant secure platform
Must be patient-initiated
May be billed by clinicians who are qualified to independently bill E/M
Cannot be used by clinical staff/clinicians who do not have E/M services in scope of practice

5. Additional Guidelines for Online Digital E/M Services
Report only once during 7-day period
7-day period begins with physician or other QHP (qualified health professional) initial, personal review of patient-generated inquiry
Cumulative service time includes:
- review of patient records or data pertinent to assessment of problem
- personal physician or QHP interaction with clinical staff focused on
patient’s problem, development of management plan, including
generation of prescriptions, ordering tests and communication
with patient through online, telephone, or other digitally-
supported communication which does not represent separately
reportable E/M service

6. Other Stipulations for Use of Digital Online E/Ms
Online interaction must be documented in permanent record
If within seven days of initiation of online service, a face-to-face E/M service occurs, time of online service or MDM complexity may be utilized by selecting a face-to-face E/M service, but, the online digital service may not be billed
If patient initiates online service within 7 days of an E/M service for the same problem, the online service is not billable
If patient initiates online service within 7 days of an E/M service for a new problem, the online service is billable
Only for established patients
HIPAA compliance securing platform is defined as a platform such as electronic health record portal, secure or other digital applications

7. New Codes for Other Professionals for Online Services
Applicable to other professionals who may not bill E/Ms such as speech-language pathologist, physical therapists, occupational therapists, social workers, dieticians for example
Medicare is not recognizing these codes because definition includes word “evaluation” and these professionals are not allowed to perform those services
CPT codes 98970, and 98972
Medicare developing HCPCS codes (to be released 11/2019)

8. HCPCS CODES FOR QHP DIGITAL ONLINE SERVICES
GNPP1 Qualified non-physician health care professional online assessment, established patient, for up to seven days, cumulative time during the 7 days; minutes
GNPP minutes
GNPP or more minutes

9. Examples of Device/Technology for Chronic Care Remote Monitoring Codes
Chronic Condition
Example Device(s)
Diabetes
Glucometer monitoring
Obesity
Caloric intake monitoring
Hypertension
Ambulatory monitoring device; manual monitoring devices
Cardiac arrhythmia
Heart rate monitor, cardiac rhythm monitor
Dementia
Video surveillance devices, locations tracking devices
Lung disease
Continuous pulse oximetry monitoring

10. CHRONIC CARE REMOTE MONITORING CODES
99453 Remote monitoring of physiological parameters) (e.g. weight, blood pressure, pulse oximetry, respiratory flow rate), initial, set up and patient education on use of equipment Device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days Remote physiologic monitoring treatment management services, 20 minutes or more of clinical staff/physician/other QHCP time in a calendar month requiring interactive communication with the patient/caregiver during the month

11. COLLECTION AND INTERPRETATION OF DATA FOR REMOTE MONITORING
99091 Collection and interpretation of physiologic data (e.g. ECG, blood
pressure, glucose monitoring) digitally stored and/or transmitted
by the patient and/or caregiver to the physician or other qualified
healthcare professional, qualified by education, training,
licensure/regulation (when applicable) requiring a minimum of
30 minutes of time, each 30 days
Does not require interactive communication such as 99457
Requires physician or other QHP to perform
Requires 30 minutes every 30 days to bill
99457 and cannot both be billed concurrently

12. REQUIREMENTS FOR USE OF REMOTE MONITORING CODES
Patient must opt-in to service (must be documented)
Device must meet FDA definition of medical device
Device must be supplied for at least 16 days for current billing period
Service must be ordered by MD or other QHP
Data must be wirelessly synced where it can be evaluated
Data-monitoring may be performed by MD, QHP or clinical staff.
Clinical staff may include RN, medial assistants, depending on state
law and scope of practice

13. COMPARISON OF USE OF 99457/99091 CPT Code 99457 CPT Code 99091
Requires 20 minutes professional time per calendar month
Requires 30 minutes professional time per 30 day period
Time spent by physicians/QHCP or clinical staff (cannot be billed incident to)
Reimbursed only for physicians or QHCPs
Requires interactive communication between provider and patient/caregiver
No communication required

14. IMPORTANCE OF MDM AND ITS ROLE IN 2021 E/Ms
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15. MEDICAL DECISION-MAKING COMPONENTS REDEFINED
CPT
DIAGNOSIS/MGT
DATA
RISK
2019
Number of diagnosis or management options
Amount and/or complexity of data to be reviewed
Risk of complications and/or morbidity or mortality
2021
Number and complexity of problem(s) addressed
Amount and/or complexity of data to be reviewed and analyzed
Risk of complications and/or morbidity or mortality of patient management

16. MDM DEFINITIONS REDEFINED
Number of Dx/Management Options renamed “Number and Complexity of Problems Addressed”
Amount and/or Complexity of Data to Be Reviewed” renamed “Amount and/or Complexity of Data to Be Reviewed and Analyzed”
Risk of Complications and/or Morbidity or Mortality renamed “Risk of Complications and/or Morbidity or Mortality of Patient Management”
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17. MDM OR TIME WILL BE DETERMINING FACTOR FOR E/Ms 99202-99215
Medical decision making or time will be the basis for code selection in 2021
Time definition will be redefined as follows:
CPT
Time Definition
2019
Typical time (with summary of face-to-face counseling and/or coordination of care)
2021
Total time
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18. IMPLEMENTATION CHANGES TO E/Ms FOR 2021

19. GENERAL CHANGES TO E/M FOR 2021
Will be included in CPT 2021
Medicare may produce HCPCS codes with specific guidance for Medicare-contracted providers in some instances
CPT code will be deleted from CPT
History and exams will still be required “commensurate” with the level of service reported, however, no auditing will be performed for these components
MDM or time will be the determining factor for
Time component redefined (as previously discussed)
Elimination of requirement to re-document information previously documented by clinical staff or on previous visit(s)

20. ADDITIONAL CHANGES TO E/M SECTION OF CPT
Restructuring of E/M guidelines into 3 subsections:
- Guidelines common to all E/M Services
- Guidelines for Hospital Observation, Hospital Inpatient, Consultations,
Emergency Department, Nursing Facility, Domiciliary, Rest Home or
Custodial Care and Home E/M Services
- Guidelines for Office or other Outpatient
Retain 5 levels for Office/Outpatient Established Patients
Reduce Office/Outpatient New Patients to 4 levels (eliminating 99201)

21. What Can YOU Do to Prepare?
Keep up-to-date on upcoming changes
Make your practice aware of the changes
Develop an impact analysis for your practice
Utilize your practice’s service analysis/productivity report to determine the specific impact to your practice
Financial impact will not be as significant as originally proposed, since 5 EP levels and 4 NP levels will remain for Outpatient/Office
Work on educating providers on documentation requirements for MDM
Recent MARSI audit demonstrated that 37-42% of all E/Ms did not meet MDM for level assigned

22. How Do We Benefit? Decreased Risk for Audit
As part of proposed changes, CMS intent on decreasing amount of chart
reviews/audits
Decreased Burden of Documentation Requirements
Physicians will be able to document less in many instances, and not be as
concerned about meeting “bullets”

23. How Will This Affect the Coding Industry and You?
Change on Focus
While coder/auditor of E/M levels may not be auditing levels to the same extent, their primary role will be determine which elements will be utilized by the practice for determining their levels and making sure all elements are met
Documentation Review
Will still involve reviewing based on time or MDM
Ensure Appropriate Documentation is Validated by Provider
Chief complaint/Patient History
Changes in History/Exam from Previous Visit(s)

24. 2020 Surgery Changes: Integumentary-Nervous System
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25. New Codes Autologous Grafting CPT Codes 15769-15774
15769 Autologous soft tissue grafting, other, harvested by direct excision(e.g. fat, dermis, fascia)
Harvested by liposuction technique, trunk, breasts, scalp, arms and/or legs, 50 cc or less injectate
each addtl 50 cc injectate or part thereof
Harvested by liposuction technique, face, eyelids, mouth, neck, orbits, genitalia, hands and/or feet, 25 cc or less injectate
each addtl 25 cc injectate or part thereof

26. Deletion of Mastectomy Codes
19260 Excision chest wall tumor including ribs
(moved to M/S CPT code 21601)
with plastic reconstruction, w/out mediastinal lymphadenectomy (new CPT code 21602)
with mediastinal lymphadenectomy (new CPT code 21603)
19304 Subcutaneous Mastectomy

27. New Codes Musculoskeletal Section
Needle insertion, without injection (1-2 muscles)
or more muscles
Drug Delivery Devices
Manual preparation* and insertion drug delivery device, deep (subfascial)
Removal drug delivery device, deep
Manual preparation and insertion drug delivery device, intramedullary
Removal drug delivery device, intramedullary
Manual preparation and insertion drug delivery device, intraarticular
Removal drug delivery device, intraarticular
* Includes mixing/preparation of drugs or therapeutic agent and shaping mixture for insertion
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28. Edit to Nasal Endoscopy Codes
Codes (Nasal endoscopy/surgical)
Removal of word “dilation” from description
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29. New Codes Cardiovascular (Pericardium)
33016 Pericardiocentesis, including fluoro/US imaging
33017 Pericardial drainage with insertion indwelling catheter, includes imaging, months or older w/out congenital cardiac anomaly
birth – 5 years or any age with congenital cardiac anomaly
33019 Pericardial drainage with insertion indwelling catheter, w/CT guidance

30. Additional Endovascular Repair Codes
Iliac artery at time of aorto-iliac artery endograft placement by deployment of iliac branched endograft (all radiological services inc), and all endograft extensions proximally to the aortic bifurcation and distally in the internal iliac, external iliac and common femoral arteries and treatment zone angioplasty/stent when performed
34718 Iliac artery, not associated with placement of aorto-iliac endograft at the same session, by deployment of iliac branched endograft, includes sizing and device selection, all ipsilateral selective iliac catheterization, all radiological services, and all endograft extensions proximally to the aortic bifurcation and distally in the internal iliac, external iliac and common femoral arteries and treatment zone angioplasty/stent when performed

31. Addition of Exploration Cardiovascular Codes
35702 Exploration, not followed by surgical repair, upper extremity
lower extremity

32. New Hemorrhoidectomy Code
46948 Hemorrhoidectomy, internal, by transanal hemorrhoidal dearterialization, 2 or more columns/groups, including guidance when performed

33. Abdomen, Peritoneum/Omentum
49013 Preperitoneal pelvic packing for hemorrhage associated with pelvic trauma (includes local exploration)
49014 Re-exploration pelvic wound with removal preperitoneal pelvic packing, including repacking, when performed.

34. SPINAL INJECTION/DESTRUCTION CODE ADDITIONS
64451 Injection, Anesthetic Agents, and/or Steroids, innervating sacroiliac joint w/imaging
genicular nerve branches w/imaging, when performed
64624 Destruction by neurolytic agent, genicular nerve branches, w/imaging, when performed
64625 Radiofrequency ablation, nerves innervating sacroiliac joint, with imaging guidance
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35. NEW CATARACT REMOVAL CODES
66987 Complex extracapsular cataract extraction with IOL (same as 66982) with endoscopic cyclophotocoagulation
66988 Extracapsular cataract extraction with IOL (same as 66984) with endoscopic cyclophotocoagulation

36. 2020 Radiology Changes:
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37. RADIOLOGY ADDITIONS/CHANGES
New code for double-contrast esophagus study CPT code 74221
Codes 74251/74245 codes deleted, utilized 74240
New code for small intestine follow-through study, includes multiple serial imaging

38. New Codes Myocardial Imaging
78430 Single Study, at rest or stress, with concurrently acquired CT transmission scan
78431 Multiple study (ies), at rest or stress, with concurrently acquired CT transmission scan
78432 Positron emission tomography, combined perfusion with metabolic evaluation study and/or ejection fraction, when performed, dual radiotracer
with concurrently acquired CT transmission scan
Absolute quantitation of myocardial blood flow, positron emission tomography, rest and stress

39. New Localization of Tumor Radiologic Codes
78830 Radiopharmaceutical localization of tumor, tomographic (SPECT) with concurrently acquired CT transmission scan for anatomic review, localization and determination/detection of pathology, single area (such as head, neck, chest, pelvic), single day imaging
SPECT only, Minimum 2 areas, single day imaging, or single area imaging over 2 or more days
SPECT and concurrently acquired CT transmission scan, minimum 2 areas, single day imaging, or single area imaging over 2 or more days
78835 Radiopharmaceutical quantification measurement(s), single area

40. 2020 Pathology Changes
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41. NEW THERAPEUTIC DRUG ASSAYS
80145 Adalimumab
80230 Infliximab
80235 Lacosamide
80187 Posaconazole
80280 Vedolizumab
80285 Voriconazole

42. This Photo by Unknown Author is licensed under CC BY-NC-ND
2020 Medicine Changes:

43. ADDITIONAL MOLECULAR PATHOLOGY/PROPRIETARY LABORATORY ANALYSES
See Molecular Pathology Section for code additions
81307
81308
81309
See Proprietary Laboratory Analyses section for code additions:
0062U 0066U 0070U 0074U+ 0078U-0138U
0063U 0067U 0071U U+
0064U 0068U 0072U U+
0065U 0069U 0073U U

44. Additional Health Behavior Assessment and Intervention Codes
Addition of codes to encompass:
Individual vs Group vs Family
Individual Time (Initial 30 minutes, each additional 15 minutes0
With/Without Patient Present

45. NEW IMMUNIZATIONS
90694 Influenza Virus, quadrivalent (all V4), inactivated, adjuvanted, preservative free, 0.5 ml dosage, IM use
90619 Meningococcal conjugate vaccine, serogroups, A, C , W, Y, quadrivalent, tetanus toxoid carrier (Med ACWY-TT), for IM use
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46. ADDITIONAL BIOFEEDBACK CODES
90912 Perineal muscles, anorectal, or urethral sphincter, inc EMG and/or manometry when performed, initial 15 minutes one-on-one qualified health care professional contact with patient
each additional 15 minutes

47. ADDITIONAL OPHTHALMOSCOPY CODES
92201 Extended ophthalmoscopy, with retinal drawing and scleral depression of peripheral retinal disease (retinal tear, retinal detachment, retinal tumor), with interpretation and report, unilateral/bilateral
92202 Extended ophthalmoscopy, with drawing of optic nerve or macular (glaucoma, macular pathology, tumor) with interpretation and report, unilateral/bilateral

48. COMPLETE REVAMPING OF EEG STUDIES
Additional Codes performed by EEG Tech:
95700 EEG continuous recording, with video when performed, minimum 8 channels
95705 EEG without video, 2-12 hours, unmonitored
with intermittent monitoring and maintenance
w/continuous real-time monitoring and maintenance
95708 EEG without video, hours, unmonitored
with intermittent monitoring and maintenance
w/continuous real-time monitoring and maintenance
95711 EEG with video, 2-12 hours, unmonitored
with intermittent monitoring and maintenance
w/continuous real-time monitoring and maintenance

49. EEG STUDY CODES (continued)
EEG, with video, hours, unmonitored
with intermittent monitoring and maintenance
w/continuous real-time monitoring and maintenance
Additional codes performed by MD or QHCP
95717 EEG, 2-12 hours, recorded without video
with video
greater than 12 hours-26 hours, without video
with video
greater than 36 hours-60 hours, without video
with video
greater than 60 hours-84 hours, without video
with video
greater than 84 hours, without video
with video
* Refer to Long-term EEG Monitoring Table, p. 715, 2020 CPT Professional Edition

50. QUESTIONS/COMMENTS/CONCERNS:
Marsha S. Diamond, CPC, COC, CCS, CPMA, AAPC Fellow & Claire

51. & Chloe Too!