2014 CPT Codes: What Your Practice Needs to Know. December 12, 2013

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1 2014 CPT Codes: What Your Practice Needs to Know December 12, 2013

2 2014 CPT Changes 335 changes, 175 new codes, 107 revisions, 47 deletions Changes to upper and lower GI codes, breast biopsies, peripheral vascular stents and chemodenervation Always changes to terminology, editorial comments for consistency

3 CPT developed by the AMA New updates annually New codes developed based on physician descriptions of services provided CMS adopts Relative Value Units, suggested by the AMA s Relative Value Update Committee, commonly called The RUC

4 CPT: source documentation AMA s 2014 Current Procedural Terminology Professional version: changes in green Appendix B: Summary of additions, deletions and revisions

5 CPT: changes AMA s Changes: An Insider s View CPT 2014 Important reference describes rationale, clinical examples

6 Key points about CPT Symbols at bottom of page are key Is it a new code or revised description? Add-on code? Code with moderate sedation bundled into code itself? Out of sequence indicator. Editorial comments Explains key thinking. Directs coder to other codes. Answers common questions: hidden in plain sight.

7 Procedures done together When two services are reported together more than 75% of the time by physicians, the codes are bundled together in subsequent years Many changes to cardiology Supervision and Interpretation codes/imaging guidance bundled into more procedures as code sections are revised

8 New E/M codes in interprofessional telephone/internet assessment and management service provided by consultative physician including a verbal and written report to patient s treating/requesting physician or other qualified health care professional Codes are selected based on time Medicare has assigned a status indicator of bundled to these services

9 Time increments: 5-10 minutes; 11-21; and over 30 minutes AMA developed these non-face-to-face services to describe consulting between physicians or physician and other provider Requires complex and/or urgent situation, where in person consult may not be feasible Not to be used if consultant agrees to accept patient in transfer

10 Patient not defined as new or established To use, consultant may not have seen patient within past 14 days or if appointment/service scheduled within next 14 days Includes review of medical records Greater than 50% of time must be devoted to medical consultative verbal/internet discussion.

11 Medicare will not pay Has assigned a status indicator of bundled to the procedure No allowance or reimbursement May not bill a Medicare patient for a bundled service Example of AMA developing codes, CMS developing reimbursement policy

12 New add-on codes for neonates Total body systemic hypothermia in a critically ill neonate per day Selective head hypothermia in a critically ill neonate per day Use in conjunction with 99291, 99292, 99468, Replaces category III codes 0260T 0261T Active code, carrier priced Out of sequence in CPT (indicated by #)

13 Breast biopsy coding changes 19100, breast biopsy not using imaging guidance Image-guided breast biopsy with placement of location device: new codes for Imaged-guided placement of localization devices without biopsy Add on codes for more than one biopsy or placement

14 Multiple biopsies or devices Guidelines for reporting multiple biopsies for location device placements using different modalities in editorial comments When more than one biopsy or localization device placement is performed using the same imaging modality, use an add-on code. If additional biopsies are performed using different modalities, report another primary code for each additional modality.

15 Excision of lesions Open excision of breast lesions that do not require attention to surgical margin resection For cysts, benign or malignant tumors See and editorial comments Existing codes

16 Removal: shoulder and deleted Removal of foreign body, shoulder; subcutaneous deep (subfascial or intramuscular) Removal of prosthesis, includes debridement and synovectomy when performed; humeral or glenoid component humeral and glenoid components

17 Removal: elbow Removal of prosthesis, includes debridement and synovectomy when performed; humeral and ulnar components radial head Existing codes, revised descriptions

18 New codes for peripheral stenting Transcatheter placement of an intravascular stent(s) intrathoracic common carotid artery or innominate artery by retrograde treatment, via open ipsilateral cervical carotid artery exposure, including angioplasty, when performed, and radiological supervision and interpretation Retrograde treatment through an open cervical carotid artery exposure

19 Iliac and lower extremity arterial anatomy territory : transcather placement of stents New codes Include add-on codes in this section All include moderate sedation

20 Vascular embolization or occlusion new codes Arteries, veins or lymphatics may be target of embolization Bundles supervision and interpretation (S&I), intraprocedural road mapping and imaging needed to complete procedure Defined for venous; arterial; tumors, organ ischemia or infarction; and arterial or venous with hemorrhage

21 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, varioceles) arterial for tumors, organ ischemia, or infarction for arterial or venous hemorrhage or lymphatic extravasation

22 Changes to GI system AMA has developed a grid to help in transition :attached to this presentation American Gastroenterological Association has developed a crosswalk: attached to this presentation

23 GI section Many codes out of sequence Parent code revision descriptions for many codes Multiple comments not separately reportable with. New code includes balloon dilation, guide wire insertion and ablation

24 Many changes this year and next Upper GI codes changed this year: 26 new codes, 41 revisions, 17 deletions Lower GI codes changing in 2015

25 Changes Language in guidelines clarifies that control of bleeding during an endoscopic procedure is not separately reportable Codes in this section out of sequence Parent codes are 43191, 43197, 43200, 43235, 43260; separate procedures

26 Endoscopy Esophagoscopy Esophagogastroduodenoscopy (EGD) Codes out of sequence 43233, 43266, Endoscopic Retrograde Cholangiopancreatography (ERCP)

27 Esophagoscopy Rigid transoral; flexible transnasal, transoral From CPT: Includes examination from the cricopharyngeus muscle (upper esophageal sphincter) to and including the gastroesophageal junction. It may also include examination of the proximal region of the stomach via retroflexion when performed. Surgical endoscopy always includes diagnostic endoscopy.

28 Esophagoscopy Some codes include moderate sedation , 43197, Some codes do not include moderate sedation Symbol in CPT book and appendix in CPT book tells you

29 Endoscopic mucosal resection (EMR) Can include injection-assisted, cap-assisted and ligation-assisted techniques Involves: Identification and demarcation of the lesion Submucosal injection to lift the lesion, and Endoscopic snare resection

30 Esophagogastroduodenoscopy EGD EGD flexible, transoral; diagnostic, with collection of specimen (s) by brushing or washing, when performed When duodenum is not examined Use modifier 52 if no planned repeat exam Use modifier 53 if repeat exam is planned

31 EGD Code revisions Moderate sedation in , 43233, 43266, (last three in same family, out of sequence) Codes out of sequence New codes: balloon > or= 30 mm EUS with transmural injection with EMR stent placement ablation

32 EGD EGD with endoscopic ultrasound, see 43237, , with endoscopic ultrasound: see revisions with transmural drainage of pseudocyst revised: includes placement of transmural drainage catheters/stents

33 Endoscopic retrograde cholangiopancreatography ERCP revised New codes, revisions, out of sequence Stent placement Foreign body or stent removal Removal and exchange of stents Balloon dilation Ablation

34 Intraoperative Neurophysiology 95940, Out of sequence No change to code descriptions Clarifies how monitoring time is calculated May not include time for setup, recording, and interpreting baseline studies or time spent removing electrodes at the end of the procedure in the monitoring time

35 Chemodenervation codes and deleted for neck muscles; for larynx May be reported with modifier 50 for bilateral new codes for service, defined by 4, 5, or 6 muscles Defined for extremity or trunk Review editorial comments: do not report with, report only once, etc.

36 Abscess drainage Codes deleted include: 47011, 48511, 49021, 49041, 49061, 50021, These were system specific codes Replaced with code 10030: next slide

37 New code in skin section Image-guided fluid collection drainage by catheter (eg abscess, hematoma, seroma, lympocele, cyst), soft tissue (eg, extremity, abdominal wall, neck) percutanous Report for each individual collection drained with a separate catheter Do not report in conjunction with 75989, 76942, 77002, 77003, 77012, 77021

38 Abscess drainage For image-guided fluid collection drainage, percutaneous or transvaginal/transrectal of visceral, peritoneal, or retroperitoneal collections, see

39 Changes for 2013 Review changes for your specialty Your specialty society Recommended source documents: CPT 2014 Professional Edition CPT Changes: An Insiders View

40 Thank you Betsy Nicoletti Follow me on

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