2016 CPT coding changes and their effects

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18 2016 CPT coding changes and their effects by

1 CPT coding changes and their effects by Linda Barney, MD, FACS, and Mark T. Savarise, MD, FACS

Significant Current Procedural Terminology (CPT)* coding changes are being implemented in 2016. Notably, some of these changes reverse last year s temporary coding for endoscopy procedures.

2 Significant Current Procedural Terminology (CPT)* coding changes are being implemented in Notably, some of these changes reverse last year s temporary coding for endoscopy procedures. This article provides reporting and payment information about the codes that are relevant to general surgery and its related specialties. Lower GI endoscopy The American Medical Association (AMA) CPT Editorial Panel revised the lower gastrointestinal (GI) endoscopy code set for 2015, which required a review of physician values within the Medicare physician fee schedule (MPFS) final rule. As that change was under review in 2014, the American College of Surgeons, the American Society of Colon and Rectal Surgeons, the Society of American Gastroenterological Surgeons, and several gastrointestinal medical societies conducted AMA/Specialty Society Relative Value Scale Update Committee (RUC) surveys for physician and offered their recommendations. However, the RUC as a whole disagreed with the specialty recommendations and proposed different values for some of the codes. The RUC submitted its recommendations on the physician relative value units (s) for calendar year 2015 to the Centers for Medicare & Medicaid Services (CMS). However, CMS delayed implementing changes to the values for the lower GI codes, citing the new process for including proposed values for new, revised, and potentially misvalued codes in the proposed rule (instead of the final rule) as one reason for the delay. In concert with this decision, CMS implemented temporary Healthcare Common Procedure Coding System (HCPCS) G-codes for a number of the new lower GI endoscopy procedures. For calendar year 2016, CMS has deleted the G-codes and accepted the CPT codes for reporting the newly defined procedures. CMS also has *All specific references to CPT codes and descriptions are 2015 American Medical Association. All rights reserved. CPT and CodeManager are registered trademarks of the American Medical Association. implemented new s for the entire set of lower GI endoscopy codes using an incremental difference methodology that differs from the RUC and society recommendations for some of the codes. An incremental methodology uses a base code or other comparable code and considers what the difference should be between that code and another code by comparing the incremental differential. Table 1 (pages 20 22) presents the lower GI endoscopy code set for 2016, along with a comparison of the 2015 and 2016 MPFS s. To read more about these coding and payment changes in the final MPFS rule, go to Medicare-Fee-for-Service-Payment/PhysicianFeeSched/ PFS-Federal-Regulation-Notices-Items/CMS-1612-FC.html. The Colonoscopy Decision Tree (see Figure 1, page 23) is designed to assist with correct CPT code and modifier selection. Soft-tissue localization Two new Category I codes were established to report initial and additional lesion placement of soft-tissue localization device(s), including imaging guidance. If a more specific site descriptor than soft tissue is applicable (for example, breast), the site-specific code for marker placement at that site should be reported. In addition, the new codes should only be reported once per target, regardless of how many markers (that is, clips, wires, pellets, and radioactive seeds) are used to mark that target. These new codes may be used to report placement of localization device(s) for axillary lymph nodes following biopsy and include the following ( = new code for 2016, + = add-on code): 10035, Placement of soft tissue localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous, including imaging guidance; first lesion , each additional lesion (list separately in addition to code for primary procedure) continued on page JAN 2016 BULLETIN American College of Surgeons

3 TABLE LOWER GI ENDOSCOPY CODING AND WORK CHANGES 20 CPT code Ileoscopy, through stoma Descriptor Percent change Ileoscopy, through stoma; diagnostic, including collection of specimen(s) by brushing or % Ileoscopy, through stoma; with transendoscopic balloon dilation 0.00* 1.48 n/a Ileoscopy, through stoma; with biopsy, single or multiple Ileoscopy, through stoma; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed) Endoscopic evaluation of small intestinal pouch Endoscopic evaluation of small intestinal pouch (eg, Kock pouch, ileal reservoir [S or J]); diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) Endoscopic evaluation of small intestinal pouch (eg, Kock pouch, ileal reservoir [S or J]); with biopsy, single or multiple Colonoscopy through stoma Colonoscopy through stoma; diagnostic, including collection of specimen(s) by brushing or Colonoscopy through stoma; diagnostic, including collection of specimen(s) by brushing or n/a 1.41 n/a Colonoscopy through stoma; with biopsy, single or multiple Colonoscopy through stoma; with removal of foreign body(s) Colonoscopy through stoma; with control of bleeding, any method Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique 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) Colonoscopy through stoma; with endoscopic stent placement (including pre- and postdilation and guide wire passage, when performed) Colonoscopy through stoma; with endoscopic mucosal resection 0.00* 5.60 n/a Colonoscopy through stoma; with directed submucosal injection(s), any substance 0.00* 3.12 n/a Colonoscopy through stoma; with transendoscopic balloon dilation 0.00* 3.33 n/a Colonoscopy through stoma; with endoscopic ultrasound examination, limited to the sigmoid, descending, transverse, or ascending colon and cecum and adjacent structures 0.00* 4.20 n/a Colonoscopy through stoma; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s), includes endoscopic ultrasound examination limited to the sigmoid, descending, 0.00* 5.06 n/a transverse, or ascending colon and cecum and adjacent structures Colonoscopy through stoma; with decompression (for pathologic distention) (eg, volvulus, megacolon), including placement of decompression tube, when performed 0.00* 4.24 n/a *Reported with unlisted code and carrier priced for continued on next page

4 TABLE LOWER GI ENDOSCOPY CODING AND WORK CHANGES (CONTINUED) CPT code Sigmoidoscopy, flexible Descriptor Percent change Sigmoidoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or % Sigmoidoscopy, flexible; with biopsy, single or multiple Sigmoidoscopy, flexible; with removal of foreign body(ies) Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps Sigmoidoscopy, flexible; with control of bleeding, any method Sigmoidoscopy, flexible; with directed submucosal injection(s), any substance Sigmoidoscopy, flexible; with decompression (for pathologic distention) (eg, volvulus, megacolon), including placement of decompression tube, when performed Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique Sigmoidoscopy, flexible; with transendoscopic balloon dilation Sigmoidoscopy, flexible; with endoscopic ultrasound examination Sigmoidoscopy, flexible; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(ies) Sigmoidoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes preand post-dilation and guide wire passage, when performed) Sigmoidoscopy, flexible; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed) Sigmoidoscopy, flexible; with endoscopic mucosal resection 0.00* 3.62 n/a Sigmoidoscopy, flexible; with band ligation(s) (eg, hemorrhoids) 0.00* 1.78 n/a Colonoscopy, flexible Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) Colonoscopy, flexible; with removal of foreign body(s) Colonoscopy, flexible; with biopsy, single or multiple Colonoscopy, flexible; with directed submucosal injection(s), any substance Colonoscopy, flexible; with control of bleeding, any method Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique Colonoscopy, flexible; with transendoscopic balloon dilation Colonoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed) *Reported with unlisted code and carrier priced for continued on next page JAN 2016 BULLETIN American College of Surgeons

TABLE 1. 2015 2016 LOWER GI ENDOSCOPY CODING AND WORK CHANGES (CONTINUED) 22 CPT code *Reported with unlisted code and carrier priced for 2015.

5 TABLE LOWER GI ENDOSCOPY CODING AND WORK CHANGES (CONTINUED) 22 CPT code *Reported with unlisted code and carrier priced for Descriptor Percent change Colonoscopy, flexible; with endoscopic stent placement (includes pre- and post-dilation and guide wire passage, when performed) % Colonoscopy, flexible; with endoscopic mucosal resection 0.00* 6.14 n/a Colonoscopy, flexible; with endoscopic ultrasound examination limited to the rectum, sigmoid, descending, transverse, or ascending colon and cecum, and adjacent structures Colonoscopy, flexible; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s), includes endoscopic ultrasound examination limited to the rectum, sigmoid, descending, transverse, or ascending colon and cecum, and adjacent structures Colonoscopy, flexible; with decompression (for pathologic distention) (eg, volvulus, megacolon), including placement of decompression tube, when performed 0.00* 4.78 n/a Colonoscopy, flexible; with band ligation(s) (eg, hemorrhoids) 0.00* 4.30 n/a Screening endoscopy G0104 Colorectal cancer screening; flexible sigmoidoscopy G0105 Colorectal cancer screening; colonoscopy on individual at high risk G Colorectal cancer screening; colonoscopy on individual at high risk G0121 Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk G Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk Open treatment of rib fracture without fixation Code 21805, Open treatment of rib fracture without fixation, each, was deleted from the 2016 CPT code set and determined to be obsolete and reportable with other CPT codes. In current practice, an injured rib when treated in an open fashion is either resected (eg, 21600) or treated with some form of internal fixation (eg, codes ). For more information on treatment of rib fractures code sets, refer to the January 2015 issue of the Bulletin.* Intravascular ultrasound Two new Category I add-on codes were established to report noncoronary intravascular ultrasound (IVUS) during diagnostic evaluation *Barney L, Savarise MT CPT coding changes will have mixed effects on payment for general surgeons. Bull Am Coll Surg. 2015;100(1): and/or therapeutic intervention. In addition, codes and and related radiological supervision and interpretation codes and were deleted. All transducer manipulations and repositioning within the specific vessel examined during a diagnostic procedure or before, during, and/or after therapeutic intervention (such as stent or stent graft placement, angioplasty, atherectomy, embolization, thrombolysis, and transcatheter biopsy) is bundled into the IVUS codes and may not be reported separately. However, non-selective and/or selective vascular catheterization may be separately reportable (for example, codes ). The two new IVUS Category I add-on codes include the following: , Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation;

COLONOSCOPY DECISION TREE *Reprinted with permission, American Medical Association. 23 CPT five-digit codes, two-digit number modifiers, and descriptions only are copyright of the AMA.

6 COLONOSCOPY DECISION TREE *Reprinted with permission, American Medical Association. 23 CPT five-digit codes, two-digit number modifiers, and descriptions only are copyright of the AMA. No payment schedules, fee schedules, s, scales, conversion factors, or components thereof are included in CPT. The AMA is not recommending that any specific relative values, fees, payment schedules, or related listings be attached to CPT. Any s or relative listings assigned to CPT codes are not those of the AMA, and the AMA is not recommending use of these relative values. initial noncoronary vessel (List separately in addition to code for primary procedure) each additional noncoronary vessel (List separately in addition to code for primary procedure) Mediastinoscopy with biopsy Two new CPT Category I codes (39401 and 39402) were established to replace code 39400, Mediastinoscopy, includes biopsy(ies), when performed. The new codes differentiate mediastinoscopy for biopsy of a mediastinal mass from lymph node biopsy(ies). Over the last 10 years, the number of mediastinoscopies performed has steadily declined. This decrease is attributable to the development and refinement of noninvasive lung cancer staging modalities such as computed tomography (CT) and positron emission tomography (PET). Additionally, pathologic staging of lung cancer can now be done using the less invasive technique of endoscopic bronchoscopic ultrasound (EBUS)-guided biopsy. Mediastinoscopy is most commonly performed for the staging of lung cancer and is used only when the previously mentioned modalities are inconclusive. It also is performed in patients deemed to be high risk for lung surgery (such as patients with chronic obstructive pulmonary disease). While the proper staging of lung cancer, which may involve the systematic biopsying of designated lymph node stations, is critical for determining appropriate treatment, mediastinoscopy can also be used to establish a diagnosis in patients with a large mediastinal mass. These are distinctly different patient populations. The two new codes allow for more accurate reporting of the different procedures and patient populations. These two new mediastinoscopy with biopsy codes include the following: JAN 2016 BULLETIN American College of Surgeons

24 39401, Mediastinoscopy; includes biopsy(ies) of mediastinal mass (eg, lymphoma), when performed 39402, with lymph node biopsy(ies) (eg, lung cancer staging) Heterotopic liver transplantation Code

7 , Mediastinoscopy; includes biopsy(ies) of mediastinal mass (eg, lymphoma), when performed 39402, with lymph node biopsy(ies) (eg, lung cancer staging) Heterotopic liver transplantation Code 47136, Liver allotransplantation; heterotopic, partial or whole, from cadaver or living donor, any age was deleted from the 2016 CPT code set. This procedure (also known as auxiliary liver transplantation) involved leaving the recipient organ in place while transplanting a donor liver in a different (ectopic) location. When introduced, heterotopic liver allotransplantation was believed to be useful for reversible liver disease whereby the transplanted liver could be removed once the native liver recovered. However, this technique has been associated with increased surgical complications and is unsuitable for liver diseases where the native liver is at risk of further disease. The procedure is rarely performed in the U.S. and therefore was deleted. A reference was added to use 47399, Unlisted procedure, liver to report this procedure. Esophageal sphincter augmentation Two new Category III codes were established to report insertion and removal of a magnetic bead band on the esophageal sphincter for treatment of gastroesophageal reflux disease. Note that code 0392T reporting is restricted to placement of a magnetic band. In addition, placement of an esophageal sphincter augmentation device should not be reported at the same time as any other fundoplication procedure. The new codes include the following: 0392T, Laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device (ie, magnetic band) 0393T, Removal of esophageal sphincter augmentation device Note Accurate coding is the responsibility of the provider. This summary is intended only to serve as a resource to assist in the billing process. Laparoscopic transhepatic cholangiography Codes 47560, Laparoscopy, surgical; with guided transhepatic cholangiography, without biopsy and 47561, Laparoscopy, surgical; with guided transhepatic cholangiography with biopsy were deleted from the 2016 CPT code set. These codes were developed prior to 1990 to report cholangiography using a laparoscope in jaundiced patients with diagnoses that remained obscure despite complete clinical, laboratory, and X ray evaluation. In the absence of laparoscopic examination, the next logical step in the diagnostic up would have been laparotomy. With advances in imaging (including magnetic resonance imaging and CT) and technology (including percutaneous transhepatic cholangiography), laparoscopic transhepatic cholangiography is no longer standard practice.

The focus of Chapter 9 is on anoscopy, proctosigmoidoscopy, flexible sigmoidoscopy, and colonoscopy procedures and all

9 Anoscopy, 45380 45380 45385 Proctosigmoidoscopy, Flexible Sigmoidoscopy, and Colonoscopy 45378 The focus of Chapter 9 is on anoscopy, proctosigmoidoscopy, flexible sigmoidoscopy, and colonoscopy procedures