1. January 2014 Jean C. Russell, MS, RHIT jrussell@epochhealth.comjrussell@epochhealth.com Richard Cooley, BA, CCS rcooley@epochhealth.comrcooley@epochhealth.com Matthew H. Lawney MSPT, MBA, CHC, mlawney@epochhealth.commlawney@epochhealth.com 518-430-1144

2. 2 Agenda Breast Biopsy Procedures Pacemaker, Cardiac Defibrillators Angiography Vascular Embolism and Occlusion Questions and Discussion

3. 3 Increased Packaging for Imaging Guidance CMS is considering conditionally packaging all imaging services performed with a surgical procedure Comments have been requested This is also an increasing pattern under CPT

4. 4 Breast Biopsy Changes – Pre-Op Needle Localization Procedures

5. 5 Pre-Op Needle Localization The following codes are deleted: – 19290 – Preoperative needle placement, breast – 19291 – Each additional – 77031 - Stereotactic guidance for breast bx or needle placement, each lesion – 77032 – Mammo guidance for needle placement, each lesion

6. 6 Pre-Op Needle Localization The following codes are not deleted, but cannot be reported for breast biopsy guidance: – 76942 – US guidance for needle placement or biopsy – 77021 – MRI guidance for needle placement of biopsy The following codes are not deleted, but cannot be reported for breast biopsy specimen exams: – 76098 – Radiologic exam of surgical specimen – 76999 – US exam of surgical specimen

7. 7 Placement of Localization Devices w/o the Biopsy The following codes are new in 2014: 19281 – Placement of localization device (e.g., clip, wire), first lesion, using mammographic guidance 19282 – Each additional lesion 19283 – Placement of localization device (e.g., clip, wire), first lesion, using stereotactic guidance 19284 – Each additional 19285 – Placement of localization device (e.g., clip, wire), first lesion, using ultrasound guidance 19286 – Each additional 19287 – Placement of localization device (e.g., clip, wire), first lesion, using MRI guidance 19288 – Each additional

8. 8 Pre-Op Needle Localization Breast Bx 19125 and 19126+, excision breast lesion identified by pre-op needle loc, open, have not been changed Pre-op needle placement (19290/19291) has been replaced: – 19281/19282, stereotactic guidance replaces 19290/19291/19295/77032 19283/19284, ultrasound guidance replaces 19290/19291/19295/77031 19285/19286, MRI guidance replaces 19290/19291/77021

9. 9 Breast Biopsy Changes – Needle Core and Vacuum Assisted Bx Under Guidance

10. 10 Breast Bx Under Guidance The following codes are deleted: – 19102 – Bx of breast, needle core, using imaging – 19103 – Bx of breast, vacuum assisted, using imaging – 19295 – Image guided placement of a clip during breast bx/aspiration, report in addition to primary procedure – 77031 - Stereotactic guidance for breast bx or needle placement, each lesion

11. 11 Breast Bx Under Guidance The following codes are not deleted, but cannot be reported for breast biopsy guidance: – 76942 – US guidance for needle placement or biopsy – 77021 – MRI guidance for needle placement of biopsy The following codes are not deleted, but cannot be reported for breast biopsies: – 76098 – Rad exam of surgical specimen – 76999 – Us exam of surgical specimen

12. 12 Breast Bx Under Guidance The following codes are new in 2014 (19102/19103): – 19081 – Bx breast, w/ placement of localization device (e.g., clip), and imaging of the biopsy specimen, first lesion, using stereotactic guidance 19082 – Each additional lesion – 19083 – Bx breast, w/ placement of localization device (e.g., clip), and imaging of the biopsy specimen, first lesion, using ultrasound guidance 19084 – Each additional – 19085 – Bx breast, w/ placement of localization device (e.g., clip), and imaging of the biopsy specimen, first lesion, using MRI guidance 19086 – Each additional

13. 13 Breast Bx Under Guidance New codes include: Image guided biopsy Placement of localization device Guidance – whether stereotactic, US, or MRI Placement of post-op clip (19295) Imaging of the biopsy specimen (76098) If more than one imaging is performed, report the additional procedure for each additional modality If an open, incisional biopsy is performed after image guided biopsy, report 19101, bx breast, open, incisional

14. 14 Breast Bx Without Guidance Breast biopsies without image guidance are still reported with: 19000, breast bx; percutaneous, needle core, not using imaging (separate procedure) 19101, … open/incisional

15. 15 Bx Under Guidance Modified NCCI Policy: “If a breast biopsy, needle localization wire, metallic localization clip, or other breast procedure is performed with mammographic guidance (e.g., 19281,19282), the physician should not separately report a post procedure mammography code (e.g., 77051, 77052, 77055-77057, G0202-G0206) for the same patient encounter. The radiologic guidance codes include all imaging by the defined modality required to perform the procedure.”

16. 16 Changes in APC Reimbursement

17. 17 Changes in APC Reimbursement

18. 18 Pacemaker/Pacing Cardio- defibrillator (ICD) Changes

19. 19 Modified Guidelines Revision of a skin pocket is included in 33206- 33249, 33262-33264 Pocket revisions that include I&D of hematoma/wound infection or debridement may be separately reported Relocation of a skin pocket – when performed as part of an explant of an existing generator followed by replacement with a new generator, the pocket relocation is reported separately 33222 – Revision/relocation of skin pocket, pacemaker 33223 - … ICD

20. 20 Subcutaneous ICDs Category III codes 0319T-0328T These are for subcutaneous ICDs (S-ICDs) FDA recently approved a new type “A subcutaneous implantable defibrillator system is an implantable technology that uses a subcutaneous pulse generator attached to a single subcutaneous electrode to treat ventricular tachy-arrhythmias.”

21. 21 Angiography/Embolism Changes

22. 22 Angiography Changes CPT is moving to bundled imaging codes for angiography when the procedures are performed under guidance more than 75% of the time The codes for endovascular revascularization were previously bundled with the guidance when performed on peripheral vessels in the lower extremity The new change is for intravascular stenting of vessels other than the lower extremity, cervical carotid, intracranial, intracoronary, extracranial or intrathoracic

23. 23 Lower Extremity Revascularization New combination codes created in 2011: 37220-37235 Reported for lower extremity revascularization services performed for occlusive disease Built on progressive hierarchy with more intensive services inclusive of less intensive services Includes: accessing/selectively catheterizing the vessel, traversing the lesion, radiology S&I directly related, embolic protection, closure of the arteriotomy, imaging to document completion

24. 24 Transcatheter Stent Placement Changes The following codes have been deleted: 37205 – Transcath placement of a stent, percutaneous, initial vessel 37206 – Each additional 37207 – Transcath placement of a stent, open, initial vessel 37208 – Each additional 75960 – Guidance of stent placement

25. 25 Transcatheter Stent Placement Changes The following codes have been added: 37236 – Transcath placement of a stent, open or percutaneous, initial artery, including imaging and angioplasty within the same vessel 37237 – Each additional 37238 – Transcath placement of a stent, open or percutaneous, initial vein, including imaging and angioplasty within the same vessel 37239 – Each additional

26. 26 Transcatheter Stent Placement Changes Code selection based on: Arterial versus venous Initial “vessel” versus additional “vessel”

27. 27 Transcatheter Stent Placement Changes The new codes not for areas where other, more specific codes exist Report just one code when there is more than one stent in a single vessel New codes include: PTA [percutaneous angioplasty] in the treated vessel Any pre-dilation Post dilation Radiological S&I Closure by pressure or closure device or suture

28. 28 Transcatheter Stent Placement Changes New codes do not include: PTA in a separate vessel Both selective and non-selective vascular catheterization Extensive repair of a artery (e.g., 35228, 35286) US guidance for vascular access (e.g., 76937) Initial dx angiography (as defined by CPT)

29. 29 Vascular Embolization and Occlusion The following code has been deleted: 37204 – Tranacath occlusion/embolization (e.g, tumor destruction, to achieve hemostasis, to occlude a vascular malformation), percutaneous, an method, non-central nervous system, non-head / neck Was frequently reported with these codes: 75894 - Transcatheter therapy, embolization, any method, radiological supervision and interpretation 75898 - Angiography through existing catheter for follow-up study for transcatheter therapy, embolization or infusion, other than for thrombolysis

30. 30 Vascular Embolization and Occlusion 37204 is now bundled with 75894 and 75898 Head/neck embolization remains the same: 61626 - Transcatheter permanent occlusion or embolization (eg, for tumor destruction, to achieve hemostasis, to occlude a vascular malformation), percutaneous, any method; non-central nervous system, head or neck (extracranial, brachiocephalic branch) 75894 75898

31. 31 Vascular Embolization and Occlusion New Codes: 37241-Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; venous, other than hemorrhage (eg, congenital or acquired venous malformations, venous and capillary hemangiomas, varices, varicoceles) - AV access branch embolization 37242 - … arterial, other than hemorrhage or tumor (eg, congenital or acquired arterial malformations, arteriovenous malformations, arteriovenous fistulas, aneurysms, pseudoaneurysms) – translumbar AAA sac coil embolization or splenic artery aneurysm embolization

32. 32 Vascular Embolization and Occlusion New Codes 37243- Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; for tumors, organ ischemia, or infarction (e.g., uterine fibroid embolization, tumor embolization, chemoembolization) 37244 - …for arterial or venous hemorrhage or lymphatic extravasation (e.g., embolization of vessel perforation or GI bleeding source embolization)

33. 33 Vascular Embolization and Occlusion Embolization includes: All radiological S&I Intra-procedural guidance and road mapping necessary to document completion of the procedure Embolization does not include: Selective and non-selective vascular catheterization(s) US guidance for vascular access (76937) Intravascular ultrasound (37250, 37251) Initial dx angiography (as defined by CPT)

34. 34 Vascular Embolization and Occlusion Stenting and Embolization for Aneurysm Treatment: When stent is placed for providing a latticework for deployment of embolization coils (e.g., aneurysm embolization), the embolization code is reported rather than the stent code If a covered stent is deployed as the sole management of an aneurysm, extra-vascularisation, then he stent deployment code should be reported rather than the embolization code

35. 35 Questions and Discussion

36. 36 Contact Us Richard Cooley Phone: 518-430-1144 Email: RCooley@EpochHealth.ComRCooley@EpochHealth.Com Matthew Lawney Phone: 845-642-6462 Email: mlawney@EpochHealth.Commlawney@EpochHealth.Com Jean Russell Phone: 518-369-4986 Email: JRussell@EpochHealth.ComJRussell@EpochHealth.Com

37. 37 http://www.EpochHealth.com/

38. 38 CPT ® Current Procedural Terminology (CPT®) Copyright 2013 American Medical Association All Rights Reserved Registered trademark of the AMA

39. 39 Disclaimer Information and opinions included in this presentation are provided based on our interpretation of current available regulatory resources. No representation is made as to the completeness or accuracy of the information. Please refer to your payer or specific regulatory guidelines as necessary.