2014 CPT Changes - wolterskluwerlb.com · 2014 CPT Changes Wolters Kluwer ... • Complex wound repair code family. ... distant to allow fracture fixation. Open treatment is used

$Page 1: 2014 CPT Changes - wolterskluwerlb.com · 2014 CPT Changes Wolters Kluwer ... • Complex wound repair code family. ... distant to allow fracture fixation. Open treatment is used$
0011 0010 1010 1101 0001 0100 1011

2014 CPT Changes

Wolters Kluwer – Mediregs

Georgeann Edford RN, MBA, CCS-P

1Georgeann Edford RN, MBA, CCS-PMember, WK Coding Advisory Board

0011 0010 1010 1101 0001 0100 1011

Outline of Webinar

• RUC (Relative Value Update Committee) Valuation Process

• 2014 Physician Fee Schedule Update

• Universal Changes

• General Surgery (10000 Series Codes)

• Orthopedics (20000 Series Codes)

• Vascular Surgery (30000 Series)

• Gastroenterology (40000 Series)

• Otolaryngology/Ophthalmology (60000 Series)

Georgeann Edford RN, MBA, CCS-PMember, WK Coding Advisory Board

2

0011 0010 1010 1101 0001 0100 1011

Outline - Continued

• Neurology (60000 Series)

• Radiology (70000 Series)

– Radiation Oncology

• Pathology (80000 Series)

• Medicine (90000 Series)

– Psychotherapy

– Neurology/Intraoperative Neurophysiology Monitoring

– E&M

• Chronic Care Management

• Transitional Care


Disclaimer: This is a very brief summary of the CPT code changes for 2014. The information presented in this presentationwere prepared by Georgeann Edford and not Wolters Kluwer. The sections presented are not all inclusive and some changeswere not included due to the nature of the topic and time limitation.

0011 0010 1010 1101 0001 0100 1011

RBRVS Valuation

• The annual adjustments to RVUs cannot cause annual estimatedexpenditures to differ by more than $20 million from what theywould have been had the adjustments not been made.

• For 2014, Psychologists and social workers’ see rates will rise 8%,while psychiatrists’ pay will increase 6%, according to anestimated impact table in the final rule.

• Chiropractors are the stand-outs next year with a 12% payincrease.

• Diagnostic testing facility payments will drop 11%, pathology by6% and independent labs by 5%.Timeline is as follows:

– Published Proposed Rule: July 8, 2013

– Comment Period Deadline: December 31, 2013


0011 0010 1010 1101 0001 0100 1011

RBRVS Valuation

• CMS announced new rate dropped from 24.4% in the proposedrule to 20.1% in the final Medicare physician fee schedule releasedNov. 27.

• Medicare payment reduced by 26.5 percent across the Board

• Conversion factor for 2014 is $27.2006

• The 2014 national average anesthesia conversion factor is$17.2283, a cut of 21.4%.

• Timeline is as follows:

– Published Rules: November 27, 2013

– Effective Date: January 1, 2014 for most services.

– Comment Period Deadline: January 27, 2014

– Secondary Effective Date: January 27, 2014


0011 0010 1010 1101 0001 0100 1011

Key Changes – Physician Fee Schedule

• Misvalued PFS Codes.

• Telehealth Services.

• Applying Therapy Caps to Outpatient Therapy Services Furnished byCAHs.

• Requiring the Compliance with State law as a Condition of Payment forServices Furnished Incident to Physician and Other Practitioner Services.

• Updating the—

– ++ Physician Compare Web site.

– ++ Physician Quality Reporting System.

– ++ Electronic Health Record (EHR) Incentive Program.

– ++ Medicare Shared Savings Program.

• Budget Neutrality for the Chiropractic Services Demonstration.

• Physician Value-Based Payment Modifier and the Physician FeedbackReporting Program


6

0011 0010 1010 1101 0001 0100 1011

Potentially Misvalued Codes

• Medicare statute requires the review of RVUs no less often thanevery five years

– Part of original RBRVS regulations

• Beginning in CY 2009, CMS and the AMA’s Relative Value ScaleUpdate Committee “RUC” identify and review potentiallymisvalued codes on an annual basis

• Approximately 1,000 codes were reviewed and revised.


0011 0010 1010 1101 0001 0100 1011

Potential Misvalued Codes

• Affordable Care Act requires CMS and the RUC to examine potentiallymisvalued codes in 7 categories.

1. Codes and families of codes for which there has been the fastest growth.

2. Codes and families of codes that have experienced substantial changes inpractice expense.

3. Codes that are recently established for new technologies or services.

4. Multiple codes that are frequently billed in conjunction with furnishing asingle service.

5. Codes with low relative values; those that are billed multiple times for asingle service

6. Codes that have not been reviewed since the implementation of RBRVS

7. Other codes determined by the Secretary

• 2013 potentially misvalued codes:

– Harvard-valued codes

– Publically nominated CPT codes

– Services with stand alone PE procedure time


0011 0010 1010 1101 0001 0100 1011

CPT Nomenclature Changes


0011 0010 1010 1101 0001 0100 1011

Universal changes

• Introduction and Instructions contain clarifications regarding useand placement of a code within a given section

• Instructions for:

– Requests to Update CPT Nomenclature

– Code Change Applications

– Criteria for Category I and Category III codes

• Base codes and the use of add-on codes:

– Orthopedics

– Psychotherapy

• Parenthetical changes throughout


0011 0010 1010 1101 0001 0100 1011

INTEGUMENTARY SURGERY

Integumentary System CPT series 10000


11

0011 0010 1010 1101 0001 0100 1011

WOUND REPAIRS & CLOSURES

• Complex wound repair code family.

– Code 13150 was deleted and cross reference was added directingusers to simple or intermediate wound closures.

– Code 13151 was revised to be a parent code.

• Repair (Closure) – Other Flaps and Grafts

– Revision of descriptor for Code 15777: Implantation of biologicimplant for soft tissue reinforcement to (i.e., breast, truck) as it isexclusively for breast or trunk.

– Six instructional notes still follow regarding implants in certainanatomic areas.


12

0011 0010 1010 1101 0001 0100 1011

BREAST BIOPSIES

• Breast Marker Placement

– Significant revisions to introductory language and 8 new codes

– New bundled codes created to report placement of breast localizationdevices with imaging guidance

– Breast marker placement are reported in the absence of breast biopsyand are categorized by:

• Mammographic guidance

• Stereotactic guidance

• Ultrasound guidance

• MRI guidance

Each has an add-on code


13

0011 0010 1010 1101 0001 0100 1011

BREAST BIOPSIES

• Breast biopsies, without image guidance are reported with 19100and 19101. Image-guided breast biopsies, including the placementof localization devices when performed, are reported using codes19081-19086.

• Image-guided placement of localization devices without image-guided biopsy are reported with 19281-19288.

• When more than one biopsy or localization device placement isperformed using the same imaging modality, use an add-on code.

• When an open incisional biopsy is performed after image-guidedplacement of a localization device, 19101 is reported and theappropriate image-guided localization device placement code isreported.

• The open excision of breast lesions, without specific attention toadequate surgical margins, with or without the preoperativeplacement of radiological markers, is reported using codes 19110-19126.


14

0011 0010 1010 1101 0001 0100 1011

BREAST BIOPSIES

• 19081 Biopsy, breast, with placement of breast localizationdevice(s) (E.G., clip, metallic pellet), when performed, and imagingof the biopsy specimen, when performed, percutaneous; firstlesion, including stereotactic guidance

19082 each additional lesion, including stereotactic guidance (Listseparately in addition to code for primary procedure)

• 19083 Biopsy, breast, with placement of breast localizationdevice(s) (E.G., clip, metallic pellet), when performed, and imagingof the biopsy specimen, when performed, percutaneous; firstlesion, including ultrasound guidance

19084 each additional lesion, including ultrasound guidance (Listseparately in addition to code for primary procedure)

• 19085 Biopsy, breast, with placement of breast localizationdevice(s) (E.G., clip, metallic pellet), when performed, and imagingof the biopsy specimen, when performed, percutaneous; firstlesion, including magnetic resonance guidance


15

0011 0010 1010 1101 0001 0100 1011

GENERAL SURGERY

• Partial mastectomy procedures are reported using codes 19301 or19302 as appropriate. Documentation for partial mastectomyprocedures includes attention to the removal of adequate surgicalmargins surrounding the breast mass or lesion.

• Total mastectomy procedures include simple mastectomy,complete mastectomy, subcutaneous mastectomy, modifiedradical mastectomy, radical mastectomy, and more extendedprocedures (E.G., Urban type operation). Total mastectomyprocedures are reported using codes 19303-19307 as appropriate.

• Excisions or resections of chest wall tumors including ribs, with orwithout reconstruction, with or without mediastinallymphadenectomy, are reported using codes 19260, 19271, or19272. Codes 19260-19272 are not restricted to breast tumorsand are used to report resections of chest wall tumors originatingfrom any chest wall component.


16

0011 0010 1010 1101 0001 0100 1011

ORTHOPAEDICS

Musculoskeletal System CPT series 20000


0011 0010 1010 1101 0001 0100 1011

Summary of Changes

• Revised introductory guidelines for “excision of subcutaneous softtissue tumors” and “radical resection of soft tissue tumors”

• Updated definitions for Fracture treatment

• Revised codes for:

– Excisions of soft tissues of :

• Head, neck and thorax

• Back and flank

• Abdomen, thigh, knees and toes

• Humerus, elbow and shoulder

• Forearm and/or wrist area, hand, fingers

– Removal of prosthesis humeral and ulnar components

• New codes for removal of foreign body for shoulder, deep andremoval of prosthesis of humeral and/or glenoid

• Newly added cross-references


0011 0010 1010 1101 0001 0100 1011

MUSCULOSKELETAL CHANGES

• Fracture Definitions:

– Closed treatment: Fracture site is NOT surgically opened; may or maynot be manipulated. Closed treatment is used to describe proceduresthat treat fractures by three methods:

1) without manipulation;

2) with manipulation; or

3) with or without traction.

– Open treatment: Surgical incision either directly at fracture site ordistant to allow fracture fixation. Open treatment is used when thefractured bone is either:

1) surgically opened (exposed to the external environment) and thefracture (bone ends) visualized and internal fixation may be used; or

2) the fractured bone is opened remotely from the fracture site in order toinsert an intramedullary nail across the fracture site (the fracture site isnot opened and visualized).


19

0011 0010 1010 1101 0001 0100 1011


• Definitions (Continued)

– Percutaneous skeletal fixation describes fracture treatment which isneither opened nor closed. Fracture fragments are not visualized, butfixation (E.g. pins) are placed across the fracture site usually undersome form of imaging. (External fixation)

– Manipulation is used throughout the fracture and dislocationsubsections to describe the reduction or restoration of a fracture orjoint dislocation to its normal anatomic alignment by the applicationof manually applied forces.


20

0011 0010 1010 1101 0001 0100 1011


• Introductory Guideline Changes:

– The “Excision of subcutaneous soft tissue tumors” introductoryguidelines were revised to clearly indicate that these codes are to bereported for connective tissue tumors and to further instruct users toreport codes 11400-11446 for the excision of benign lesions ofcutaneous origin (E.g., sebaceous cyst).

– For consistency and uniformity, the introductory guidelines for theradical resection of soft tissue tumors were also revised to clearlyindicate that these codes are to be reported for connective tissuetumor procedures.


21

0011 0010 1010 1101 0001 0100 1011


• Introductory Guidelines

– These tumors are usually benign and are resected without removing asignificant amount of surrounding normal tissue.

• Code selection is based on the location and size of the tumor and isdetermined by measuring the greatest diameter of the tumor plus thatmargin required for complete excision of the tumor.

• The margins refer to the most narrow margin required to adequatelyexcise the tumor, based on the physician’s judgment. The measurement ofthe tumor plus margin is made at the time of the excision.

• The measurement of the tumor plus margin is made at the time of theexcision. Appreciable vessel exploration and/or neuroplasty should bereported separately. Extensive undermining or other techniques to close adefect created by skin excision may require a complex repair whichshould be reported separately


0011 0010 1010 1101 0001 0100 1011


• Excision of fascial or subfascial soft tissue tumors (includingsimple or intermediate repair) involves the resection of tumorsconfined to the tissue within or below the deep fascia, but notinvolving the bone.

• Radical resection of soft connective tissue tumors (includingsimple or intermediate repair) involves the resection of the tumorwith wide margins of normal tissue.

• Radical resection of bone tumors (including simple orintermediate repair) involves the resection of the tumor with widemargins of normal tissue.

• Numerous parenthetical guidelines!


23

0011 0010 1010 1101 0001 0100 1011


• Introductions and Removals

1. Numerous changes due to changes in prosthetics and technique toremove them. E.g. Shoulder prosthesis 23333-23335

– For example: 23330 Removal of foreign body, shoulder;subcutaneous (23331, 23332 have been deleted) (To report removalof foreign body, see 23330, 23333)

• 23333 deep (subfascial or intramuscular)

• 23334 Removal of prosthesis, includes debridement and synovectomywhen performed; humeral or glenoid component

• 23335 humeral and glenoid components (e.g., total shoulder)

– (Do not report 23334, 23335 in conjunction with 23473, 23474 if a prosthesis [i.e.,humeral and/or glenoid component(s)] is being removed and replaced in the sameshoulder during the same surgical session) (To report removal of hardware, other thanhumeral and/or glenoid prosthesis, use 20680)

2. Use of specialized equipment to avoid bone loss or fracture and thecomplete removal of cement to avoid infection requires specialosteotomes, high-speed surgical drills and ultrasound.


24

0011 0010 1010 1101 0001 0100 1011

CARDIOTHORACIC

CPT 30000 Series


0011 0010 1010 1101 0001 0100 1011

HEART & PERICARDIUM - NEW CODES

• Last year – TAVI and TAVR as Category III codes. Now Category I.

• Codes 33361, 33362, 33363, 33364, 33365 and 33366 are used toreport transcatheter aortic valve replacement (TAVR) andtranscatheter valve implantation (TAVI).

• TAVI and TAVR require two physician operators and allcomponents of the procedure are reported using Modifier 62.

– 33361 – Transcatheter aortic valve replacement (TAVR/TAVI) withprosthetic valve;

• 33362 – open femoral artery approach

• 33363 – open axillary approach

• 33364 – open iliac artery approach

• 33365 – transthoracic approach (e.g. median sternotomy,mediastinotomy)


FDAApproved9/2013

0011 0010 1010 1101 0001 0100 1011

HEART & PERICARDIUM - NEW GUIDELINES

• Codes 33361, 33362, 33363, 33364, 33365, 33366 are used to reporttranscatheter aortic valve replacement (TAVR)/transcatheter aortic valveimplantation (TAVI). TAVR/TAVI requires two physician operators and allcomponents of the procedure are reported using modifier 62.

• Codes 33361, 33362, 33363, 33364, 33365, 33366 include the work,when performed, of percutaneous access, placing the access sheath,balloon aortic valvuloplasty, advancing the valve delivery system intoposition, repositioning the valve as needed, deploying the valve,temporary pacemaker insertion for rapid pacing (33210), and closure ofthe arteriotomy when performed. Codes 33361, 33362, 33363, 33364,33365, 33366 include open arterial or cardiac approach.

• Angiography, radiological supervision, and interpretation performed toguide TAVR/TAVI (e.g., guiding valve placement, documenting completionof the intervention, assessing the vascular access site for closure) areincluded in these codes.


0011 0010 1010 1101 0001 0100 1011

HEART & PERICARDIUM - NEW GUIDELINES(Continued)

• Diagnostic left heart catheterization codes (93452, 93453, 93458-93461) and thesupravalvular aortography code (93567) should not be used with TAVR/TAVIservices (33361, 33362, 33363, 33364, 33365, 33366) to report:

1. Contrast injections, angiography, road mapping, and/or fluoroscopic guidance for theTAVR/TAVI,

2. Aorta/left ventricular outflow tract measurement for the TAVR/TAVI, or

3. Post-TAVR/TAVI aortic or left ventricular angiography, as this work is captured in theTAVR/TAVI services codes (33361, 33362, 33363, 33364, 33365, 33366).

• Diagnostic coronary angiography performed at the time of TAVR/TAVI may beseparately reportable if:

1. No prior catheter-based coronary angiography study is available and a full diagnosticstudy is performed, or

2. A prior study is available, but as documented in the medical record:

a. The patient’s condition with respect to the clinical indication has changed since theprior study, or

b. There is inadequate visualization of the anatomy and/or pathology, or

c. There is a clinical change during the procedure that requires new evaluation.

d. For same session/same day diagnostic coronary angiography services, report theappropriate diagnostic cardiac catheterization code(s) appended with modifier 59indicating separate and distinct procedural service from TAVR/TAVI.


0011 0010 1010 1101 0001 0100 1011

HEART AND PERICARDIUM (Continued)

• Endovascular Repair Of Abdominal Aortic Aneurysm Codes 34800-34826 represent a family of component procedures to reportplacement of an endovascular graft for abdominal aortic aneurysmrepair.

• These codes describe open femoral or iliac artery exposure, devicemanipulation and deployment, and closure of the arteriotomysites.

• Balloon angioplasty and/or stent deployment within the targettreatment zone for the endoprosthesis, either before or afterendograft deployment, are not separately reportable.

• Introduction of guidewires and catheters should be reportedseparately (E.g., 36200, 36245-36248, 36140).

• Extensive repair or replacement of an artery should beadditionally reported (E.g., 35226 or 35286).


0011 0010 1010 1101 0001 0100 1011

HEART AND PERICARDIUM (Continued)

• 34800 Endovascular repair of infrarenal abdominal aorticaneurysm or dissection; using aorto-aortic tubeprosthesis

– 34802 using modular bifurcated prosthesis (1 docking limb)

– 34803 using modular bifurcated prosthesis (2 docking limbs)

– 34804 using unibody bifurcated prosthesis

– 34805 using aorto-uniiliac or aorto-unifemoral prosthesis


30

0011 0010 1010 1101 0001 0100 1011

PACEMAKERS, CARDIOVERTER-DEFIBRILLATOR

• New instructions added to guidelines discussing relocation of“pockets”

• New codes for revision of a skin pocket: 33206-33249, 33262-33264.

• Revised parentheticals


31

0011 0010 1010 1101 0001 0100 1011

VASCULAR SURGERY

CPT Series 348XX


32

0011 0010 1010 1101 0001 0100 1011

ENDOVASCULAR REPAIR OF ABDOMINALAORTIC ANEURYSM (EVAR)

• Codes 34800-34826 represent a family of component proceduresto report placement of an endovascular graft for abdominal aorticaneurysm repair.

• These codes describe open femoral or iliac artery exposure, devicemanipulation and deployment, and closure of the arteriotomysites.

• Balloon angioplasty and/or stent deployment within the targettreatment zone for the endoprosthesis, either before or afterendograft deployment, are not separately reportable.

• Introduction of guidewires and catheters should be reportedseparately (eg, 36200, 36245-36248, 36140).

• Extensive repair or replacement of an artery should beadditionally reported (eg, 35226 or 35286 ).


33

0011 0010 1010 1101 0001 0100 1011

FENESTRATED ENDOVASCULAR REPAIR OFABDOMINAL AORTIC ANEURYSM (FEVAR)

• Fenestrated aortic repair is reported based on the extent of aortatreated. Codes 34841-34844 describe repair using proximalendoprostheses that span from the visceral aortic component toone, two, three, or four visceral artery origins and distal extentlimited to the infrarenal aorta.

• These devices do not extend into the common iliac arteries. Codes34845-34848 are used to report deployment of a fenestratedendoprosthesis that spans from the visceral aorta (including one,two, three, or four visceral artery origins) through the infrarenalaorta into the common iliac arteries.

• The infrarenal component may be a bifurcated unibody device, amodular bifurcated docking system with docking limb(s), or anaorto-uniiliac or aorta-unifemoral device.


34

0011 0010 1010 1101 0001 0100 1011

FENESTRATED ENDOVASCULAR REPAIR OFABDOMINAL AORTIC ANEURYSM (FEVAR)

• Codes 34845-34848 include placement of unilateral or bilateraldocking limbs (depending on the device). Any additional stentgraft extensions that terminate in the common iliac arteries areincluded in the work described by 34845-34848.

• Codes 34825 and 34826 may not be separately reported forproximal abdominal aortic extension prosthesis(es) or for distalextension prosthesis(es) that terminate in the aorta or thecommon iliac arteries.

• Codes 34825 and 34826 may be reported for distal extensionprosthesis(es) that terminate in the internal iliac, external iliac, orcommon femoral artery(s).


35

0011 0010 1010 1101 0001 0100 1011

TRANSCATHETER PLACEMENT

• 37217 Transcatheter placement of an intravascular stent(s),intrathoracic common carotid artery or innominate artery byretrograde treatment, via, open ipsilateral cervical carotid arteryexposure, including angioplasty, when performed and radiologicsupervision and interpretation.

• Includes:

– Carotid artery open surgical exposure and standard closure of thearteriotomy site

– All retrograde access and catheterization of the vessel, traversing thelesion

– Any radiologic supervision and interpretation directly related to theintervention when performed (including diagnostic angiogram)

– Imaging performed to document completion of the intervention inaddition to the intervention(s) performed (stenting and angioplasty)

• Does not include revascularization of different sites; may bereported separately.


36

0011 0010 1010 1101 0001 0100 1011

VASCULAR INJECTION PROCEDURES

Intra-Arterial—Intra-Aortic

• Diagnostic Studies of Arteriovenous (AV) Shunts for Dialysis

– The language in the Intra-Arterial—Intra-Aortic introductoryguidelines has been revised to maintain consistency with the newstent codes 37236-37239 that now differentiate between venous andarterial stent placement.

– Further guideline revisions clarify that accessory veins are separatelycatheterized for diagnosis or intervention. In addition, the language“once, irrespective of the number of branches embolized” was addedto clarify that 37241 would be reported only once, even if multiplebranches are embolized.


37

0011 0010 1010 1101 0001 0100 1011

ENDOVASCULAR STENT PLACEMENT

• New subsection added to Endovascular Revascularization

– 37236, 37237, 37238 and 37239. These codes are used to reportplacement of intravascular stents.

– 37236 Transcatheter placement of an intravascular stent(s)(except for lower extremity, cervical carotid, extracranial vertebral orintrathoracic carotid, intracranial or coronary) open or percutaneous,including radiologic supervision and interpretation and including allangioplasty within the same vessel, when performed; initial artery

37237 Each additional artery (list separately in addition to code forprimary procedure)

• 37238 Transcatheter placement of an intravascular stent(s), openor percutaneous, including radiologic supervision and interpretationand including all angioplasty within the same vessel, whenperformed; initial vein

37239 Each additional vein (List separately in addition to code forprimary procedure)


38

0011 0010 1010 1101 0001 0100 1011

VASCULAR EMBOLIZATION AND OCCLUSION

• Codes 37241-37244 are used to describe the work of vascularembolization and occlusion procedures, excluding the centralnervous system and the head and neck, which are reported using61624, 61626, 61710, and 75894, and excluding theablation/sclerotherapy procedures for venous insufficiency /telangiectasia of the extremities/skin, which are reported using36468, 36470, and 36471.

• Embolization and occlusion procedures are performed for a widevariety of clinical indications and in a range of vascular territories.

• Arteries, veins, and lymphatics may all be the target ofembolization.


39

0011 0010 1010 1101 0001 0100 1011

VASCULAR EMBOLIZATION AND OCCLUSION

Four new codes

• Code 37241 is used to report vascular embolization or occlusionprocedures performed for venous conditions other thanhemorrhage. Examples include embolization of venousmalformations, capillary hemangiomas, varicoceles, and visceralvarices. Embolization of side branch(es) of an outflow vein from ahemodialysis access would be reported using 37241

• Code 37242 is used to report vascular embolization or occlusionperformed for arterial conditions other than hemorrhage or tumorsuch as arteriovenous malformations and arteriovenous fistulaswhether congenital or acquired. Embolizations of aneurysms andpseudoaneurysms are also reported with 37242.


40

0011 0010 1010 1101 0001 0100 1011

VASCULAR EMBOLIZATION AND OCCLUSION• Code 37243 is used to report embolization for the purpose of

tissue ablation and organ infarction or ischemia. This can beperformed in many clinical circumstances, including embolizationof benign or malignant tumors of the liver, kidney, uterus, or otherorgans. When chemotherapy is given as part of an embolizationprocedure, additional codes (eg, 96420) may be separatelyreported. When a radioisotope (eg, Yttrium-90) is injected as partof an embolization, then additional codes (eg, 79445) may beseparately reported. Uterine fibroid embolization is reported with37243.

• Sometimes, embolization and occlusion of an artery are performedprior to another planned interventional procedure; an example isembolization of the left gastric artery prior to plannedimplantation of a hepatic artery chemotherapy port. The arteryembolization is reported with 37242.

• Code 37244 is used for arterial or venous hemorrhage orlymphatic extravasation


41

0011 0010 1010 1101 0001 0100 1011

PARENTHETICAL NOTE CHANGES

• The parenthetical note following code 36218 was revised to reflectthe deletion of codes 37205-37208 and replacement with codes37211, 37213, 37214, 37236-37239, and 37241-37244.

• An exclusionary parenthetical note following code 36227 has beenadded to preclude the reporting of arterial catheter placementcodes in conjunction with the Transcatheter stent placement code37217 for ipsilateral services.

• An exclusionary parenthetical note has been added following code36254 precluding codes 36251-36254 from being reported inconjunction with the Percutaneous renal denervation codes 0338Tand 0339T.

• An exclusionary parenthetical note has been added following code36468 to preclude the reporting of this code in conjunction withthe vascular embolization and occlusion procedure code (37241)in the same surgical field.


42

0011 0010 1010 1101 0001 0100 1011


• A parenthetical note has been added following code 36471directing users to the appropriate code for reporting vascularembolization and occlusion procedures (37241-37244).

• An exclusionary parenthetical note has also been added followingcode 36471 to preclude the reporting of 36470 and 36471 inconjunction with the vascular embolization and occlusionprocedure code (37241) in the same surgical field.

• In support of the establishment of codes 37241-37244, theexclusionary parenthetical note following codes 36475 and 36476has been revised precluding the reporting of other specifiedservices in the same surgical field.


43

0011 0010 1010 1101 0001 0100 1011


• The AMA/Specialty Society RVS Update Committee (RUC)identified the embolization surgical code (37204) and theradiological supervision and interpretation codes (75894 and75898) as being reported together 75% of the time or more.

• As a result, code 37204 has been deleted, four new bundled codes37241-37244 have been established, and a new subsection andinstructional guidelines have been added to clarify the reporting ofthese services for a wide variety of clinical indications and toprovide clarification that these new codes include all associatedradiological supervision and interpretation services.

• Parenthetical notes were also added, directing users to the newcodes 37241-37244 for vascular embolization and occlusionprocedures and another to reference code 61624 as CentralNervous System (CNS) and 61626 as head and neck fortranscatheter occlusion or embolization procedures.


44

0011 0010 1010 1101 0001 0100 1011

GASTROENTEROLOGY

CPT 40000 Series


0011 0010 1010 1101 0001 0100 1011

SUMMARY OF CHANGES

• The Esophagus/Endoscopy section has undergone substantialchanges for 2014, beginning with new Endoscopy guidelinesstating that control of bleeding that occurs as a result of theendoscopic procedure is not separately reported during the sameoperative session. In addition, the anatomic structures that areincluded in an esophagoscopy are now listed in the Endoscopyguidelines.

– Inclusion of anatomic structures in esophagoscopy codes are nowspecified

– Technology – more use of flexible versus rigid endoscopes

– Approach changes; transnasal vs. transoral

– Differentiation between parent codes and separate procedures.

• Upper endoscopy

– Espophagogastroduodenoscopy (EGD)

– Endoscopic Retrograde Cholangiopancreatography (ERCP)


0011 0010 1010 1101 0001 0100 1011

Gastroenterology Guideline Changes

• Guidelines – Purpose

– CMS Physician work and practice expense

– New technology, devices and techniques

– Standardize language across sections

– Anatomic structures included in codes are now more specific

• Differentiation between parent codes and separate procedures.

– The “separate procedure” designation is used throughout the code setto designate services/procedures that are normally included inanother procedure(s), considered an integral component of anotherprocedure. But are appropriately reported only when performedindependently from other procedures.

• PARENTHETICALS!


47

0011 0010 1010 1101 0001 0100 1011

UPPER ENDOSCOPY

• Three subsections

– Esophagoscopy: 43191-43233

– EGD codes: 43235-43259 with codes out of sequence: 43233, 43266and 43270.

– ERCP: 43260 – 43273

• Endoscopic Mucosal Resection (EMR)

– EMR can include injection assisted, capsule assisted and ligationassisted techniques.

– All techniques involve:

• Identification and demarcation of the lesions,

• Submucosal injection to lift the lesion, and

• Endoscopic snare resection.

– 43211 not reported with snare technique,


48

0011 0010 1010 1101 0001 0100 1011

ERCP

• Codes 43274, 43275, 43276, and 43277 describe ERCP with stentplacement, removal or replacement (exchange) of stent(s), andballoon dilation within the pancreatico-biliary system. Forreporting purposes, ducts that may be reported as stented orsubject to stent replacement (exchange) or to balloon dilationinclude:

– Pancreas: major and minor ducts

– Biliary tree: common bile duct, right hepatic duct, left hepatic duct,cystic duct/gallbladder


49

0011 0010 1010 1101 0001 0100 1011

ERCP

• ERCP with stent placement includes any balloon dilationperformed in that duct. ERCP with more than one stent placement(E.G., different ducts or side by side in the same duct) performedduring the same day/session may be reported with 43274 morethan once with modifier 59 appended to the subsequentprocedure(s).

• For ERCP with more than one stent exchanged during the sameday/session, 43276 may be reported for the initial stent exchange,and 43276 with modifier 59 for each additional stent exchange.

• ERCP with balloon dilation of more than one duct during the sameday/session may be reported with modifier 59 appended to thesubsequent procedure(s).

• Sphincteroplasty, which is balloon dilation of the ampulla(sphincter of Oddi), is reported with 43277, and includessphincterotomy (43262) when performed.


50

0011 0010 1010 1101 0001 0100 1011

STENT PLACEMENT

• Stent Placement

– 43219, 43256, 43267 and 43268 have been deleted and replaced withcodes 43212, 43266, and 43274. The new code descriptors specifythe inclusion of pre and post-dilitaton and guide wire passage whenperformed.

• Code 43274 also includes sphincterotomy when performed.

• Code 43266 describes the EGD procedure

– Code 43241 has been revised to make the language consistent withother descriptors in the code set. Codes 43212, 43266, and 43274 allinclude moderate sedation, as indicated by the moderate sedationsymbol.

• Dilation Procedures

– Dilation procedure codes have been added, revised, and deleted tobetter describe current practice. Esophagoscopy code 43220 and EGDcode 43249 have been revised to specify transendoscopic balloondilation of less than 30 mm in diameter.


51

0011 0010 1010 1101 0001 0100 1011

NEUROLOGY

CPT Series 646XX


52

0011 0010 1010 1101 0001 0100 1011

SURGERY - NERVOUS

• Revisions to chemodenervation codes

– Deletion of coded 64613, 64614

– Addition of codes 64616, 64617

– Addition of six new codes 64642-64647

– New and revised instructional parenthetical notes


53

0011 0010 1010 1101 0001 0100 1011

SURGERY - NERVOUS

• Somatic nerves - Chemodenervation of muscle(s)

– Deleted code 64613, 64614. Both described multiple uses ofchemodenervation of the neck , extremity and/or trunk muscles.Because they each described multiple conditions, deleted and newcodes added for specificity.

– New and revised parenthetical notes following 64615.Chemodenervation of muscle(s) innervated by facial, trigeminal,cervical spinal and accessory nerves, bilateral (eg, for chronicmigraine) (Report 64615 only once per session)

• (Do not report 64615 in conjunction with 64612, 64616, 64617, 64642,64643, 64644, 64645, 64646, 64647)

– Two new codes added; 64616 and 64617

• 64616 chemodenervation of muscle(s); neck muscle(s), excluding musclesof the larynx, unilateral (eg, for cervical dystonial, spasmodic torticollis)

• Parenthetical note added: (For chemodenervation guided by needleelectromyography or muscle electrical stimulation, see 95873, 95874. Donot report more than one guidance code for any unit of 64616).


54

0011 0010 1010 1101 0001 0100 1011

SURGERY - NERVOUS

• 64620 Destruction by neurolytic agent, intercostal nerve

• Four new extremity codes 64642, 64643, 64644, 64645

• Codes 64642, 64643, 64644, 64645. Reported once per extremitybut can be reported together up to a combined total of four units ofservice per patient when all four extremities are injected.

• Report only one base code; 64642 or 64644 per session.

• Report one or more units of additional extremity code(s) (64643or 64645) for each additional extremity injected.


55

0011 0010 1010 1101 0001 0100 1011

SURGERY - NERVOUS

• 64642: 1-4 muscles

• 64643: each additional extremity (1-4 muscles)

• 64644: 5 or more muscles

• 64645: each additional extremity, of 5 or more muscles

• Example:

– One injection into each limb: 1 unit of 64642 and 3 units of 64643[two arms and two legs]

– Five injections into each limb: 1 unit of 64644 and 3 units of 64645

– 3 injections in left arm and leg and 5 injections in right arm and leg: 1unit of 64642 and 1 unit of 64643 (left side) then 1 unit of 64644 and1 unit of 64645 (right arm and leg)

• Trunk muscles: 1-5 use 64646. For 6 or more muscles use 64647.

• No use of bilateral modifier; just count the muscles and limbs.


56

0011 0010 1010 1101 0001 0100 1011

AUDITORY AND OPHTHALMOLOGY

CPT 60000 Series


57

0011 0010 1010 1101 0001 0100 1011

EYE AND OCULAR ADNEXA

• Codes 65778 and 65779 were editorially revised to omit thephrase “for wound healing” and to substitute the term “self-retaining” with “without sutures” in the code language and cross-reference note following 65780.

• The “without sutures” in code 65778 serves to clarify and betterdistinguish between the two different techniques, non-sutured orsutured or self-retaining.

• The phrase “for wound healing” was omitted as it restricted use ofthe codes to just this purpose. Because the intent was that theproduct be used as a bandage for healing and to prevent surfacedisease, the language was revised to eliminate this restriction.


58

0011 0010 1010 1101 0001 0100 1011

EYE AND OCULAR ADNEXA

• Code 66183 has been added to report the insertion of an anteriorsegment drainage device for the management of glaucoma utilizingan external surgical approach.

• This code replaces Category III code 0192T. The glaucomafiltration device is placed to relieve intraocular pressureassociated with glaucoma that is not responding to medicaltherapy or other surgical intervention (E.G., laser trabeculoplasty).

• 67345 Chemodenervation of extraocular muscle (Forchemodenervation for blepharospasm and other neurologicaldisorders, see 64612 and 64616)

• 67938 Removal of embedded foreign body, eyelid (For repair ofskin of eyelid, see 12011-12018, 12051-12057, 13151-13153)

• 68040 Expression of conjunctival follicles (eg, for trachoma) (Toreport automated evacuation of Meibomian glands, use 0207T)


59

0011 0010 1010 1101 0001 0100 1011

AUDITORY CHANGE

• One code change

• Cerumen impaction

• Change in description and parenthetical

– 69210 Removal impacted cerumen (separate procedure) requiringinstrumentation, 1 or both ears unilateral

– (For cerumen removal that is not impacted or does not requireinstrumentation, E.G., by irrigation only, see E/M service code, whichmay include new or established patient office or other outpatientservices [99201-99215], hospital observation services [99217-99220,99224-99226], hospital care [99221-99223, 99231-99233],consultations [99241-99255], emergency department services[99281- 99285], nursing facility services [99304-99318], domiciliary,rest home, or custodial care services [99324-99337], home services[99341-99350]).


60

0011 0010 1010 1101 0001 0100 1011

RADIOLOGY

CPT 70000 Series


0011 0010 1010 1101 0001 0100 1011

RADIOLOGY CHANGES

• Diagnostic Radiology

– Revised code descriptions

• Transcatheter procedures

– In support of the establishment of vascular embolization andocclusion procedure codes 37241-37244, an exclusionaryparenthetical note following code 75894 has been added to precludethis code from being reported in conjunction with codes 36475,36476, 36478, 36479, and 37241-37244, and an exclusionaryparenthetical note following code 75898 has been revised to precludethis code from being reported in conjunction with codes 37241-37244.

• Diagnostic Ultrasound, CT, MRI and Mammography

– Guidance codes for Breast Biopsy and Vascular Embolization codes

• Fluoroscopic Guidance

– Parenthetic note changes to coincide with changes in integumentarysection.


0011 0010 1010 1101 0001 0100 1011

RADIATION ONCOLOGY

• Consultation

• Treatment Planning: Simple, Intermediate and Complex

• Simulation

• Medical Radiation Physics, Dosimetry, Treatment Devices, andSpecial Services

• Radiation Treatment Delivery

• Radiation Treatment Management

• Parenthetical Changes


63

0011 0010 1010 1101 0001 0100 1011

RADIATION ONCOLOGY CHANGES

• Treatment Planning

– Addition of new add-on code 77293 Respiratory motion managementsimulation (List separately in addition to primary procedure)

• Simulation

– Simulation description was not included in the guidelines

– Four definitions were included in the guidelines to explain simulation

– 77295 is revised (moved to be in the next section on MedicalRadiation Physics…

– Guideline changes to define three categories of Simulation.

• Simple, Intermediate and Complex

• Treatment Changes

– Definition changes from “ports” to treatment areas; simple,intermediate and complex


64

0011 0010 1010 1101 0001 0100 1011

RADIATION ONCOLOGY CHANGES

• RUC evaluation of codes in the Simulation, Medical physics,radiation treatment delivery, blocking – anticipated hugereductions and when final rule was published, Radiation Oncologywas listed as a +1%.

• However message was “stay tuned”


65

0011 0010 1010 1101 0001 0100 1011

PATHOLOGY

CPT 80000 codes


0011 0010 1010 1101 0001 0100 1011

PATHOLOGY/LABORATORY CHANGES

• Molecular Pathology

– Tier 1

• Now 107 codes, includes codes for gene-specific genome procedures

• Three new parenthetical notes

– Tier 2

• 318 new analytes

• Code revisions, instructional notes and parentheticals

• Molecular Assays with Algorithmic Analyses (MAAAs)

– New Introductory Guidelines appear before the codes before thesection starting with 81500.


0011 0010 1010 1101 0001 0100 1011

PATHOLOGY/LABORATORY CHANGES

• The new Drug Assay codes used to identify new drugs

• Major changes in drug testing for 2015 in quantitative DrugTesting

• Multianalyte Assays with Algorithmic Analyses (MAAAs)

– A multianalyte assay with algorithmic analysis (MAAA) code (81504)has been established for genetic profiling on oncology biopsy lesions(tissue of origin) to aid in determining diagnoses and treatmentoptions. The results of the microarray algorithm on the biopsy samplepresented to the laboratory in electronic report quantify thesimilarity of poorly differentiated and undifferentiated tumorspecimens to cancers from 15 known tissues of origin, for clinicalinterpretation.

– One new code

– One converted codes (From category III to category I)

– Guideline changes and PARENTHETICAL changes


0011 0010 1010 1101 0001 0100 1011

MEDICINE

CPT 90000 series


0011 0010 1010 1101 0001 0100 1011

MEDICINE CHANGES

• Vaccines/Toxoids

• Psychiatry/Psychotherapy

• Gastroenterology

• Ophthalmology

• Special Otorhinolaryngologic

• Cardiovascular

• Noninvasive vascular

• Pulmonary

• Neurology – Intraoperative Monitoring

• Hydration, Therapeutic

• Photodynamic Therapy

• Physical Medicine

• E&M


0011 0010 1010 1101 0001 0100 1011

MEDICINE CHANGES

• Vaccines: Four new and one revised code for influenza vaccine toreflect new products.

• Psychiatry: An instructional parenthetical note has been addedfollowing Medicine code 90837 to reference a 90-minute thresholdrequirement for reporting prolonged services codes 99354-99357with psychotherapy services. To coincide with this deletion, thesecond parenthetical note following 90838 referencing 68 minuteshas been deleted.

• Gastroenterology: Code 91065 has been editorially revised toinclude methane testing. As methane gas chromotographic testingis now being used to measure the end-expiratory breathspecimens, code 91065 references breath methane in addition tohydrogen.

– A parenthetical note has also been added instructing that code 91065should be reported once for each test administered.


71

0011 0010 1010 1101 0001 0100 1011

MEDICINE CHANGES

• Ophthalmology: New Category III code for 0329T for 24-hourintraocular pressure monitoring, a parenthetical note was addedafter code 92100 to instruct the use of code 0329T when amonitoring device is fitted to the patient for continuousmonitoring during a 24-hour period.

– Code 92100 represents a service that involves measurements taken atdefined intervals during the course of a one-day patient session at onelocation utilizing a standard tonometer to assess the resistance of anapplied force required to deform the natural corneal shape.


72

0011 0010 1010 1101 0001 0100 1011

MEDICINE CHANGES

• Speech Pathology: Code 92506 has been deleted and four newcodes established to clearly define and describe the wide range ofservices that were included in code 92506. Code 92506 was usedfor evaluations related to a number of distinct communicationdisorders and lacked specificity.

• Four new evaluation codes were created that relate directly to theevaluation of speech fluency, speech sound production, languagecomprehension, and expression, and analysis of voice andresonance.

• The guidelines were revised by removing deleted code 92506 andreplacing it with new codes 92521-92524.

• Parenthetical instructions added.


73

0011 0010 1010 1101 0001 0100 1011

MEDICINE CHANGES

• Cardiology: With the establishment of Category III codes forsubcutaneous implantable defibrillator systems, two parentheticalcross-references have been added to the CardiovascularImplantable and Wearable Cardiac Device Evaluations subsection.

• The parenthetical directs users to codes 0327T and 0328T forevaluation and programming of a subcutaneous implantabledefibrillator device.

• Non-invasive Vascular: Parenthetical notes have been addedfollowing codes 93922 and 93923 that exclude use of these codesin conjunction with code 0337T. This code is used to reportendothelial function assessment using the peripheral vascularresponse to hyperemia.


74

0011 0010 1010 1101 0001 0100 1011

MEDICINE CHANGES

• Pulmonary: New guidelines have been added that explain the twomethods of accomplishing chest wall manipulation (manual[94667 and 94668] or mechanical [94669]). Code is reported persession and identifies applying the device for use and/or trainingprovided by the health care professional for patient useindependently.

• Neurology: Parenthetical note changes regarding the use ofelectromyography with chemodenervation codes.


75

0011 0010 1010 1101 0001 0100 1011

MEDICINE CHANGES

• The Intraoperative Neurophysiology guidelines have been revisedto clarify appropriate calculation of time when reportingintraoperative electrophysiology monitoring services. The addedguidelines clarify that monitoring time as described by codes95940 and 95941 excludes the time for setting up, recording, andinterpreting the baseline studies, as well as removing theelectrodes at the end of the procedure. They also indicate thattime spent waiting on standby should be reported with standbyservice E/M code 99360.

• The new guidelines further explain that cumulative one-on-onetime spent in the operating room is used to determine the units ofservice for code 95940. It is possible that monitoring may beginprior to incision, for example, if positioning the patient on theoperating table prior to incision is poses a risk to the patient.


76

0011 0010 1010 1101 0001 0100 1011

EVALUATION & MANAGEMENT


77

0011 0010 1010 1101 0001 0100 1011

E&M CHANGES

• Discharge Day Management

• Guideline Changes

– Complex Chronic Care Coordination (CCCC)

– Transitional Care Management

• Addition of Clinical examples in Appendix C

• A new subsection, guidelines, and four codes (99446 – 99449) have beenestablished in the Evaluation and Management section to describeinterprofessional telephone/ Internet consultative services. These codesare for reporting interprofessional telephone/Internet consultation,which is defined in the guidelines as an assessment and managementservice in which a patient’s treating physician or other qualified healthcare professional requests the opinion and/or treatment advice of aphysician with specific specialty expertise (the consultant) to assist in thediagnosis and/or management of the patient’s problem without the needfor the patient’s face-to-face contact with the consulting physician.


78

0011 0010 1010 1101 0001 0100 1011

OTHER CHANGES TO E&M SECTION

• To conform with the CPT Nomenclature Reporting Neutralityinitiative, the parenthetical note following code 99239 was revisedto adhere to the policy of neutrality in identifying who mayperform a procedure or a service. In addition, the parentheticalnote was further clarified to address concurrent care services.

• Year of parentheticals. Changes in almost every section providingclarification and guidance.


79

0011 0010 1010 1101 0001 0100 1011

OTHER SECTION CHANGES

• Changes were made in every section of CPT. Those not covered inthis presentation were due to parenthetical changes only.


80

0011 0010 1010 1101 0001 0100 1011

Sources of information for this presentation


81

• CPT and RBRVS 2014 Symposium

• CPT 2014 Insider’s View

• 2014 CPT

• Final Rule: Physician Fee Schedule

Documents

2014 CPT Changes - wolterskluwerlb.com · 2014 CPT Changes Wolters Kluwer ... • Complex wound repair code family. ... distant to allow fracture fixation. Open treatment is used