2014 CPT Changes. Wolters Kluwer Mediregs Georgeann Edford RN, MBA, CCS-P. Georgeann Edford RN, MBA, CCS-P Member, WK Coding Advisory Board

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1 2014 CPT Changes Wolters Kluwer Mediregs 1

2 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) 2

3 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 The information presented in this presentation were prepared by Georgeann Edford and not Wolters Kluwer. The sections presented are not all inclusive and some changes were not included due to the nature of the topic and time limitation. 3

4 RBRVS Valuation The annual adjustments to RVUs cannot cause annual estimated expenditures to differ by more than $20 million from what they would 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 an estimated impact table in the final rule. Chiropractors are the stand-outs next year with a 12% pay increase. Diagnostic testing facility payments will drop 11%, pathology by 6% and independent labs by 5%.Timeline is as follows: Published Proposed Rule: July 8, 2013 Comment Period Deadline: December 31,

5 RBRVS Valuation CMS announced new rate dropped from 24.4% in the proposed rule to 20.1% in the final Medicare physician fee schedule released Nov. 27. Medicare payment reduced by 26.5 percent across the Board Conversion factor for 2014 is $ The 2014 national average anesthesia conversion factor is $ , 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,

6 Key Changes Physician Fee Schedule Misvalued PFS Codes Telehealth Services Applying Therapy Caps to Outpatient Therapy Services Furnished by CAHs. Requiring the Compliance with State law as a Condition of Payment for Services 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 Feedback Reporting Program 6

7 Potentially Misvalued Codes Medicare statute requires the review of RVUs no less often than every five years Part of original RBRVS regulations Beginning in CY 2009, CMS and the AMA s Relative Value Scale Update Committee RUC identify and review potentially misvalued codes on an annual basis Approximately 1,000 codes were reviewed and revised. 7

8 Potential Misvalued Codes Affordable Care Act requires CMS and the RUC to examine potentially misvalued codes in 7 categories Codes and families of codes for which there has been the fastest growth. 2. Codes and families of codes that have experienced substantial changes in practice expense. 3. Codes that are recently established for new technologies or services. 4. Multiple codes that are frequently billed in conjunction with furnishing a single service. 5. Codes with low relative values; those that are billed multiple times for a single 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 8

9 CPT Nomenclature Changes 9

10 Universal changes Introduction and Instructions contain clarifications regarding use and 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 10

11 Integumentary System CPT series INTEGUMENTARY SURGERY 11

12 WOUND REPAIRS & CLOSURES Complex wound repair code family Code was0100 deleted 1011 and cross reference was added directing users to simple or intermediate wound closures. Code was revised to be a parent code. Repair (Closure) Other Flaps and Grafts Revision of descriptor for Code 15777: Implantation of biologic implant for soft tissue reinforcement to (i.e., breast, truck) as it is exclusively for breast or trunk. Six instructional notes still follow regarding implants in certain anatomic areas. 12

13 Breast Marker Placement BREAST BIOPSIES Significant revisions 0100 to1011 introductory language and 8 new codes New bundled codes created to report placement of breast localization devices with imaging guidance Breast marker placement are reported in the absence of breast biopsy and are categorized by: Mammographic guidance Stereotactic guidance Ultrasound guidance MRI guidance Each has an add-on code 13

14 BREAST BIOPSIES Breast biopsies, without image guidance are reported with and Image-guided breast biopsies, including the placement of localization devices when performed, are reported using codes Image-guided placement of localization devices without imageguided biopsy are reported with When more than one biopsy or localization device placement is performed using the same imaging modality, use an add-on code. When an open incisional biopsy is performed after image-guided placement of a localization device, is reported and the appropriate image-guided localization device placement code is reported. The open excision of breast lesions, without specific attention to adequate surgical margins, with or without the preoperative placement of radiological markers, is reported using codes

15 BREAST BIOPSIES Biopsy, breast, with placement of breast localization device(s) (E.G., clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including stereotactic guidance each additional lesion, including stereotactic guidance (List separately in addition to code for primary procedure) Biopsy, breast, with placement of breast localization device(s) (E.G., clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including ultrasound guidance each additional lesion, including ultrasound guidance (List separately in addition to code for primary procedure) Biopsy, breast, with placement of breast localization device(s) (E.G., clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including magnetic resonance guidance 15

16 GENERAL SURGERY Partial mastectomy procedures are reported using codes or as appropriate. Documentation for partial mastectomy procedures includes attention to the removal of adequate surgical margins surrounding the breast mass or lesion. Total mastectomy procedures include simple mastectomy, complete mastectomy, subcutaneous mastectomy, modified radical mastectomy, radical mastectomy, and more extended procedures (E.G., Urban type operation). Total mastectomy procedures are reported using codes as appropriate. Excisions or resections of chest wall tumors including ribs, with or without reconstruction, with or without mediastinal lymphadenectomy, are reported using codes 19260, 19271, or Codes are not restricted to breast tumors and are used to report resections of chest wall tumors originating from any chest wall component. 16

17 Musculoskeletal System CPT series ORTHOPAEDICS 17

18 Summary of Changes Revised introductory guidelines for excision of subcutaneous soft tissue 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 and removal of prosthesis of humeral and/or glenoid Newly added cross-references 18

19 Fracture Definitions: MUSCULOSKELETAL CHANGES Closed 1101 treatment: Fracture 1011site is NOT surgically opened; may or may not be manipulated. Closed treatment is used to describe procedures that 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 or distant to allow fracture fixation. Open treatment is used when the fractured bone is either: 1) surgically opened (exposed to the external environment) and the fracture (bone ends) visualized and internal fixation may be used; or 2) the fractured bone is opened remotely from the fracture site in order to insert an intramedullary nail across the fracture site (the fracture site is not opened and visualized). 19

20 MUSCULOSKELETAL CHANGES Definitions (Continued) Percutaneous skeletal 0100 fixation 1011 describes fracture treatment which is neither opened nor closed. Fracture fragments are not visualized, but fixation (E.g. pins) are placed across the fracture site usually under some form of imaging. (External fixation) Manipulation is used throughout the fracture and dislocation subsections to describe the reduction or restoration of a fracture or joint dislocation to its normal anatomic alignment by the application of manually applied forces. 20

21 MUSCULOSKELETAL CHANGES Introductory Guideline Changes: The 1101 Excision 0001 of subcutaneous soft tissue tumors introductory guidelines were revised to clearly indicate that these codes are to be reported for connective tissue tumors and to further instruct users to report codes for the excision of benign lesions of cutaneous origin (E.g., sebaceous cyst). For consistency and uniformity, the introductory guidelines for the radical resection of soft tissue tumors were also revised to clearly indicate that these codes are to be reported for connective tissue tumor procedures. 21

22 MUSCULOSKELETAL CHANGES Introductory Guidelines These tumors are usually benign and are resected without removing a significant amount of surrounding normal tissue. Code selection is based on the location and size of the tumor and is determined by measuring the greatest diameter of the tumor plus that margin required for complete excision of the tumor. The margins refer to the most narrow margin required to adequately excise the tumor, based on the physician s judgment. The measurement of the tumor plus margin is made at the time of the excision. The measurement of the tumor plus margin is made at the time of the excision. Appreciable vessel exploration and/or neuroplasty should be reported separately. Extensive undermining or other techniques to close a defect created by skin excision may require a complex repair which should be reported separately 22

23 MUSCULOSKELETAL CHANGES Excision of fascial or subfascial soft tissue tumors (including simple or intermediate repair) involves the resection of tumors confined to the tissue within or below the deep fascia, but not involving the bone. Radical resection of soft connective tissue tumors (including simple or intermediate repair) involves the resection of the tumor with wide margins of normal tissue. Radical resection of bone tumors (including simple or intermediate repair) involves the resection of the tumor with wide margins of normal tissue. Numerous parenthetical guidelines! 23

24 MUSCULOSKELETAL CHANGES Introductions and Removals Numerous changes 0100 due1011 to changes in prosthetics and technique to remove them. E.g. Shoulder prosthesis For example: Removal of foreign body, shoulder; subcutaneous (23331, have been deleted) (To report removal of foreign body, see 23330, 23333) deep (subfascial or intramuscular) Removal of prosthesis, includes debridement and synovectomy when performed; humeral or glenoid component humeral and glenoid components (e.g., total shoulder) (Do not report 23334, in conjunction with 23473, if a prosthesis [i.e., humeral and/or glenoid component(s)] is being removed and replaced in the same shoulder during the same surgical session) (To report removal of hardware, other than humeral and/or glenoid prosthesis, use 20680) 2. Use of specialized equipment to avoid bone loss or fracture and the complete removal of cement to avoid infection requires special osteotomes, high-speed surgical drills and ultrasound. 24

25 CPT Series CARDIOTHORACIC 25

26 HEART & PERICARDIUM - NEW CODES Last year TAVI and TAVR as Category III codes. Now Category I. Codes 33361, 33362, 33363, 33364, and are used to report transcatheter aortic valve replacement (TAVR) and transcatheter valve implantation (TAVI) TAVI and TAVR require two physician operators and all components of the procedure are reported using Modifier Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open femoral artery approach open axillary approach open iliac artery approach transthoracic approach (e.g. median sternotomy, mediastinotomy) FDA Approved 9/

27 HEART & PERICARDIUM - NEW GUIDELINES Codes 33361, 33362, 33363, 33364, 33365, are used to report transcatheter aortic valve replacement (TAVR)/transcatheter aortic valve implantation (TAVI). TAVR/TAVI requires two physician operators and all components of the procedure are reported using modifier 62. Codes 33361, 33362, 33363, 33364, 33365, include the work, when performed, of percutaneous access, placing the access sheath, balloon aortic valvuloplasty, advancing the valve delivery system into position, repositioning the valve as needed, deploying the valve, temporary pacemaker insertion for rapid pacing (33210), and closure of the arteriotomy when performed. Codes 33361, 33362, 33363, 33364, 33365, include open arterial or cardiac approach. Angiography, radiological supervision, and interpretation performed to guide TAVR/TAVI (e.g., guiding valve placement, documenting completion of the intervention, assessing the vascular access site for closure) are included in these codes. 27

28 HEART & PERICARDIUM - NEW GUIDELINES (Continued) Diagnostic left heart catheterization codes (93452, 93453, ) and the supravalvular aortography code (93567) should not be used with TAVR/TAVI services 1010 (33361, , , , 33365, 33366) to report: 1. Contrast injections, angiography, road mapping, and/or fluoroscopic guidance for the TAVR/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 the TAVR/TAVI services codes (33361, 33362, 33363, 33364, 33365, 33366). Diagnostic coronary angiography performed at the time of TAVR/TAVI may be separately reportable if: 1. No prior catheter-based coronary angiography study is available and a full diagnostic study 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 the prior 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 the appropriate diagnostic cardiac catheterization code(s) appended with modifier 59 indicating separate and distinct procedural service from TAVR/TAVI. 28

29 HEART AND PERICARDIUM (Continued) Endovascular Repair Of Abdominal Aortic Aneurysm Codes represent a family of component procedures to report placement of an endovascular graft for abdominal aortic aneurysm repair These codes describe open femoral or iliac artery exposure, device manipulation and deployment, and closure of the arteriotomy sites. Balloon angioplasty and/or stent deployment within the target treatment zone for the endoprosthesis, either before or after endograft deployment, are not separately reportable. Introduction of guidewires and catheters should be reported separately (E.g., 36200, , 36140). Extensive repair or replacement of an artery should be additionally reported (E.g., or 35286). 29

30 HEART AND PERICARDIUM (Continued) Endovascular repair of infrarenal abdominal aortic aneurysm or dissection; using aorto-aortic tube prosthesis using modular bifurcated prosthesis (1 docking limb) using modular bifurcated prosthesis (2 docking limbs) using unibody bifurcated prosthesis using aorto-uniiliac or aorto-unifemoral prosthesis 30

31 PACEMAKERS, CARDIOVERTER-DEFIBRILLATOR New instructions added to guidelines discussing relocation of pockets New codes for revision of a skin pocket: , Revised parentheticals 31

32 CPT Series 348XX VASCULAR SURGERY 32

33 ENDOVASCULAR REPAIR OF ABDOMINAL AORTIC ANEURYSM (EVAR) Codes represent a family of component procedures to report placement of an endovascular graft for abdominal aortic aneurysm repair. These codes describe open femoral or iliac artery exposure, device manipulation and deployment, and closure of the arteriotomy sites. Balloon angioplasty and/or stent deployment within the target treatment zone for the endoprosthesis, either before or after endograft deployment, are not separately reportable. Introduction of guidewires and catheters should be reported separately (eg, 36200, , 36140). Extensive repair or replacement of an artery should be additionally reported (eg, or ). 33

34 FENESTRATED ENDOVASCULAR REPAIR OF ABDOMINAL AORTIC ANEURYSM (FEVAR) Fenestrated aortic repair is reported based on the extent of aorta treated. Codes describe repair using proximal endoprostheses that span from the visceral aortic component to one, two, three, or four visceral artery origins and distal extent limited to the infrarenal aorta These devices do not extend into the common iliac arteries. Codes are used to report deployment of a fenestrated endoprosthesis that spans from the visceral aorta (including one, two, three, or four visceral artery origins) through the infrarenal aorta into the common iliac arteries. The infrarenal component may be a bifurcated unibody device, a modular bifurcated docking system with docking limb(s), or an aorto-uniiliac or aorta-unifemoral device. 34

35 FENESTRATED ENDOVASCULAR REPAIR OF ABDOMINAL AORTIC ANEURYSM (FEVAR) Codes include placement of unilateral or bilateral docking limbs (depending on the device). Any additional stent graft extensions that terminate in the common iliac arteries are included in the work described by Codes and may not be separately reported for proximal abdominal aortic extension prosthesis(es) or for distal extension prosthesis(es) that terminate in the aorta or the common iliac arteries. Codes and may be reported for distal extension prosthesis(es) that terminate in the internal iliac, external iliac, or common femoral artery(s). 35

36 TRANSCATHETER PLACEMENT 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 radiologic supervision and interpretation Includes: Carotid artery open surgical exposure and standard closure of the arteriotomy site All retrograde access and catheterization of the vessel, traversing the lesion Any radiologic supervision and interpretation directly related to the intervention when performed (including diagnostic angiogram) Imaging performed to document completion of the intervention in addition to the intervention(s) performed (stenting and angioplasty) Does not include revascularization of different sites; may be reported separately. 36

37 VASCULAR INJECTION PROCEDURES Intra-Arterial Intra-Aortic Diagnostic Studies of Arteriovenous (AV) Shunts for Dialysis The language in the Intra-Arterial Intra-Aortic introductory guidelines has been revised to maintain consistency with the new stent codes that now differentiate between venous and arterial stent placement. Further guideline revisions clarify that accessory veins are separately catheterized for diagnosis or intervention. In addition, the language once, irrespective of the number of branches embolized was added to clarify that would be reported only once, even if multiple branches are embolized. 37

38 ENDOVASCULAR STENT PLACEMENT New subsection added to Endovascular Revascularization , , and These codes are used to report placement of intravascular stents Transcatheter placement of an intravascular stent(s) (except for lower extremity, cervical carotid, extracranial vertebral or intrathoracic carotid, intracranial or coronary) open or percutaneous, including radiologic supervision and interpretation and including all angioplasty within the same vessel, when performed; initial artery Each additional artery (list separately in addition to code for primary procedure) Transcatheter placement of an intravascular stent(s), open or percutaneous, including radiologic supervision and interpretation and including all angioplasty within the same vessel, when performed; initial vein Each additional vein (List separately in addition to code for primary procedure) 38

39 VASCULAR EMBOLIZATION AND OCCLUSION Codes are used to describe the work of vascular embolization and occlusion procedures, excluding the central nervous system and the head and neck, which are reported using 61624, 61626, 61710, and 75894, and excluding the ablation/sclerotherapy procedures for venous insufficiency / telangiectasia of the extremities/skin, which are reported using 36468, 36470, and Embolization and occlusion procedures are performed for a wide variety of clinical indications and in a range of vascular territories. Arteries, veins, and lymphatics may all be the target of embolization. 39

40 VASCULAR EMBOLIZATION AND OCCLUSION Four new codes Code is used to report vascular embolization or occlusion procedures performed for venous conditions other than hemorrhage. Examples include embolization of venous malformations, capillary hemangiomas, varicoceles, and visceral varices. Embolization of side branch(es) of an outflow vein from a hemodialysis access would be reported using Code is used to report vascular embolization or occlusion performed for arterial conditions other than hemorrhage or tumor such as arteriovenous malformations and arteriovenous fistulas whether congenital or acquired. Embolizations of aneurysms and pseudoaneurysms are also reported with

41 VASCULAR EMBOLIZATION AND OCCLUSION Code is used to report embolization for the purpose of tissue ablation and organ infarction or ischemia. This can be performed in many clinical circumstances, including embolization of benign or malignant tumors of the liver, kidney, uterus, or other organs. When chemotherapy is given as part of an embolization procedure, additional codes (eg, 96420) may be separately reported. When a radioisotope (eg, Yttrium-90) is injected as part of an embolization, then additional codes (eg, 79445) may be separately reported. Uterine fibroid embolization is reported with Sometimes, embolization and occlusion of an artery are performed prior to another planned interventional procedure; an example is embolization of the left gastric artery prior to planned implantation of a hepatic artery chemotherapy port. The artery embolization is reported with Code is used for arterial or venous hemorrhage or lymphatic extravasation 41

42 PARENTHETICAL NOTE CHANGES The parenthetical note following code was revised to reflect the deletion of codes and replacement with codes 37211, 37213, 37214, , and An exclusionary parenthetical note following code has been added to preclude the reporting of arterial catheter placement codes in conjunction with the Transcatheter stent placement code for ipsilateral services. An exclusionary parenthetical note has been added following code precluding codes from being reported in conjunction with the Percutaneous renal denervation codes 0338T and 0339T. An exclusionary parenthetical note has been added following code to preclude the reporting of this code in conjunction with the vascular embolization and occlusion procedure code (37241) in the same surgical field. 42

43 PARENTHETICAL NOTE CHANGES A parenthetical note has been added following code directing users to the appropriate code for reporting vascular embolization and occlusion procedures ( ) An exclusionary parenthetical note has also been added following code to preclude the reporting of and in conjunction with the vascular embolization and occlusion procedure code (37241) in the same surgical field. In support of the establishment of codes , the exclusionary parenthetical note following codes and has been revised precluding the reporting of other specified services in the same surgical field. 43

44 PARENTHETICAL NOTE CHANGES The AMA/Specialty Society RVS Update Committee (RUC) identified the embolization surgical code (37204) and the radiological supervision and interpretation codes (75894 and 75898) as being reported together 75% of the time or more As a result, code has been deleted, four new bundled codes have been established, and a new subsection and instructional guidelines have been added to clarify the reporting of these services for a wide variety of clinical indications and to provide clarification that these new codes include all associated radiological supervision and interpretation services. Parenthetical notes were also added, directing users to the new codes for vascular embolization and occlusion procedures and another to reference code as Central Nervous System (CNS) and as head and neck for transcatheter occlusion or embolization procedures. 44

45 CPT Series GASTROENTEROLOGY 45

46 SUMMARY OF CHANGES The Esophagus/Endoscopy section has undergone substantial changes for 2014, beginning with new Endoscopy guidelines stating that control of bleeding that occurs as a result of the endoscopic procedure is not separately reported during the same operative session. In addition, the anatomic structures that are included in an esophagoscopy are now listed in the Endoscopy guidelines. Inclusion of anatomic structures in esophagoscopy codes are now specified 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) 46

47 Gastroenterology Guideline Changes Guidelines Purpose CMS1101 Physician 0001work 0100and 1011 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 set to designate services/procedures that are normally included in another procedure(s), considered an integral component of another procedure. But are appropriately reported only when performed independently from other procedures. PARENTHETICALS! 47

48 Three subsections UPPER ENDOSCOPY Esophagoscopy: EGD codes: with codes out of sequence: 43233, and ERCP: Endoscopic Mucosal Resection (EMR) EMR can include injection assisted, capsule assisted and ligation assisted techniques. All techniques involve: Identification and demarcation of the lesions, Submucosal injection to lift the lesion, and Endoscopic snare resection not reported with snare technique, 48

49 ERCP Codes 43274, 43275, 43276, and describe ERCP with stent placement, removal or replacement (exchange) of stent(s), and balloon dilation within the pancreatico-biliary system. For reporting purposes, ducts that may be reported as stented or subject to stent replacement (exchange) or to balloon dilation include: Pancreas: major and minor ducts Biliary tree: common bile duct, right hepatic duct, left hepatic duct, cystic duct/gallbladder 49

50 ERCP ERCP with stent placement includes any balloon dilation performed in that duct. ERCP with more than one stent placement (E.G., different ducts or side by side in the same duct) performed during the same day/session may be reported with more than once with modifier 59 appended to the subsequent procedure(s). For ERCP with more than one stent exchanged during the same day/session, may be reported for the initial stent exchange, and with modifier 59 for each additional stent exchange. ERCP with balloon dilation of more than one duct during the same day/session may be reported with modifier 59 appended to the subsequent procedure(s). Sphincteroplasty, which is balloon dilation of the ampulla (sphincter of Oddi), is reported with 43277, and includes sphincterotomy (43262) when performed. 50

51 Stent Placement STENT PLACEMENT , , and have been deleted and replaced with codes 43212, 43266, and The new code descriptors specify the inclusion of pre and post-dilitaton and guide wire passage when performed. Code also includes sphincterotomy when performed. Code describes the EGD procedure Code has been revised to make the language consistent with other descriptors in the code set. Codes 43212, 43266, and all include moderate sedation, as indicated by the moderate sedation symbol. Dilation Procedures Dilation procedure codes have been added, revised, and deleted to better describe current practice. Esophagoscopy code and EGD code have been revised to specify transendoscopic balloon dilation of less than 30 mm in diameter. 51

52 CPT Series 646XX NEUROLOGY 52

53 SURGERY - NERVOUS Revisions to chemodenervation codes Deletion 1101of 0001 coded , Addition of codes 64616, Addition of six new codes New and revised instructional parenthetical notes 53

54 SURGERY - NERVOUS Somatic nerves - Chemodenervation of muscle(s) Deleted 1101 code , Both described multiple uses of chemodenervation of the neck, extremity and/or trunk muscles. Because they each described multiple conditions, deleted and new codes added for specificity. New and revised parenthetical notes following Chemodenervation of muscle(s) innervated by facial, trigeminal, cervical spinal and accessory nerves, bilateral (eg, for chronic migraine) (Report only once per session) (Do not report in conjunction with 64612, 64616, 64617, 64642, 64643, 64644, 64645, 64646, 64647) Two new codes added; and chemodenervation of muscle(s); neck muscle(s), excluding muscles of the larynx, unilateral (eg, for cervical dystonial, spasmodic torticollis) Parenthetical note added: (For chemodenervation guided by needle electromyography or muscle electrical stimulation, see 95873, Do not report more than one guidance code for any unit of 64616). 54

55 SURGERY - NERVOUS Destruction by neurolytic agent, intercostal nerve Four new extremity codes 64642, 64643, 64644, Codes 64642, 64643, 64644, Reported once per extremity but can be reported together up to a combined total of four units of service per patient when all four extremities are injected. Report only one base code; or per session. Report one or more units of additional extremity code(s) (64643 or 64645) for each additional extremity injected. 55

56 SURGERY - NERVOUS 64642: 1-4 muscles 64643: each additional extremity (1-4 muscles) : 5 or more muscles 64645: each additional extremity, of 5 or more muscles Example: One injection into each limb: 1 unit of and 3 units of [two arms and two legs] Five injections into each limb: 1 unit of and 3 units of injections in left arm and leg and 5 injections in right arm and leg: 1 unit of and 1 unit of (left side) then 1 unit of and 1 unit of (right arm and leg) Trunk muscles: 1-5 use For 6 or more muscles use No use of bilateral modifier; just count the muscles and limbs. 56

57 CPT Series AUDITORY AND OPHTHALMOLOGY 57

58 EYE AND OCULAR ADNEXA Codes and were editorially revised to omit the phrase for wound healing and to substitute the term selfretaining with without sutures in the code language and crossreference note following The without sutures in code serves to clarify and better distinguish between the two different techniques, non-sutured or sutured or self-retaining. The phrase for wound healing was omitted as it restricted use of the codes to just this purpose. Because the intent was that the product be used as a bandage for healing and to prevent surface disease, the language was revised to eliminate this restriction. 58

59 EYE AND OCULAR ADNEXA Code has been added to report the insertion of an anterior segment drainage device for the management of glaucoma utilizing an external surgical approach. This code replaces Category III code 0192T. The glaucoma filtration device is placed to relieve intraocular pressure associated with glaucoma that is not responding to medical therapy or other surgical intervention (E.G., laser trabeculoplasty) Chemodenervation of extraocular muscle (For chemodenervation for blepharospasm and other neurological disorders, see and 64616) Removal of embedded foreign body, eyelid (For repair of skin of eyelid, see , , ) Expression of conjunctival follicles (eg, for trachoma) (To report automated evacuation of Meibomian glands, use 0207T) 59

60 AUDITORY CHANGE One code change Cerumen impaction Change in description and parenthetical Removal impacted cerumen (separate procedure) requiring instrumentation, 1 or both ears unilateral (For cerumen removal that is not impacted or does not require instrumentation, E.G., by irrigation only, see E/M service code, which may include new or established patient office or other outpatient services [ ], hospital observation services [ , ], hospital care [ , ], consultations [ ], emergency department services [ ], nursing facility services [ ], domiciliary, rest home, or custodial care services [ ], home services [ ]). 60

61 CPT Series RADIOLOGY 61

62 Diagnostic Radiology Revised 1101code 0001 descriptions Transcatheter procedures RADIOLOGY CHANGES In support of the establishment of vascular embolization and occlusion procedure codes , an exclusionary parenthetical note following code has been added to preclude this code from being reported in conjunction with codes 36475, 36476, 36478, 36479, and , and an exclusionary parenthetical note following code has been revised to preclude this code from being reported in conjunction with codes 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 integumentary section. 62

63 RADIATION ONCOLOGY Consultation Treatment Planning: Simple, Intermediate and Complex Simulation Medical Radiation Physics, Dosimetry, Treatment Devices, and Special Services Radiation Treatment Delivery Radiation Treatment Management Parenthetical Changes 63

64 RADIATION ONCOLOGY CHANGES Treatment Planning Addition 1101of 0001 new add-on code Respiratory motion management simulation (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 is revised (moved to be in the next section on Medical Radiation 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

65 RADIATION ONCOLOGY CHANGES RUC evaluation of codes in the Simulation, Medical physics, radiation treatment delivery, blocking anticipated huge reductions and when final rule was published, Radiation Oncology was listed as a +1% However message was stay tuned 65

66 CPT codes PATHOLOGY 66

67 PATHOLOGY/LABORATORY CHANGES Molecular Pathology Tier Now 107 codes, includes codes for gene-specific genome procedures Tier 2 Three new parenthetical notes 318 new analytes Code revisions, instructional notes and parentheticals Molecular Assays with Algorithmic Analyses (MAAAs) New Introductory Guidelines appear before the codes before the section starting with

68 PATHOLOGY/LABORATORY CHANGES The new Drug Assay codes used to identify new drugs Major changes in drug testing for 2015 in quantitative Drug Testing 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 treatment options. The results of the microarray algorithm on the biopsy sample presented to the laboratory in electronic report quantify the similarity of poorly differentiated and undifferentiated tumor specimens to cancers from 15 known tissues of origin, for clinical interpretation. One new code One converted codes (From category III to category I) Guideline changes and PARENTHETICAL changes 68

69 CPT series MEDICINE 69

70 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 70

71 MEDICINE CHANGES Vaccines: Four new and one revised code for influenza vaccine to reflect new products. Psychiatry: An instructional parenthetical note has been added following Medicine code to reference a 90-minute threshold requirement for reporting prolonged services codes with psychotherapy services. To coincide with this deletion, the second parenthetical note following referencing 68 minutes has been deleted. Gastroenterology: Code has been editorially revised to include methane testing. As methane gas chromotographic testing is now being used to measure the end-expiratory breath specimens, code references breath methane in addition to hydrogen. A parenthetical note has also been added instructing that code should be reported once for each test administered. 71

72 MEDICINE CHANGES Ophthalmology: New Category III code for 0329T for 24-hour intraocular pressure monitoring, a parenthetical note was added after code to instruct the use of code 0329T when a monitoring device is fitted to the patient for continuous monitoring during a 24-hour period. Code represents a service that involves measurements taken at defined intervals during the course of a one-day patient session at one location utilizing a standard tonometer to assess the resistance of an applied force required to deform the natural corneal shape. 72

73 MEDICINE CHANGES Speech Pathology: Code has been deleted and four new codes established to clearly define and describe the wide range of services that were included in code Code was used for evaluations related to a number of distinct communication disorders and lacked specificity. Four new evaluation codes were created that relate directly to the evaluation of speech fluency, speech sound production, language comprehension, and expression, and analysis of voice and resonance. The guidelines were revised by removing deleted code and replacing it with new codes Parenthetical instructions added. 73

74 MEDICINE CHANGES Cardiology: With the establishment of Category III codes for subcutaneous implantable defibrillator systems, two parenthetical cross-references have been added to the Cardiovascular Implantable and Wearable Cardiac Device Evaluations subsection. The parenthetical directs users to codes 0327T and 0328T for evaluation and programming of a subcutaneous implantable defibrillator device. Non-invasive Vascular: Parenthetical notes have been added following codes and that exclude use of these codes in conjunction with code 0337T. This code is used to report endothelial function assessment using the peripheral vascular response to hyperemia. 74

75 MEDICINE CHANGES Pulmonary: New guidelines have been added that explain the two methods of accomplishing chest wall manipulation (manual [94667 and 94668] or mechanical [94669]). Code is reported per session and identifies applying the device for use and/or training provided by the health care professional for patient use independently. Neurology: Parenthetical note changes regarding the use of electromyography with chemodenervation codes. 75

76 MEDICINE CHANGES The Intraoperative Neurophysiology guidelines have been revised to clarify appropriate calculation of time when reporting intraoperative electrophysiology monitoring services. The added guidelines clarify that monitoring time as described by codes and excludes the time for setting up, recording, and interpreting the baseline studies, as well as removing the electrodes at the end of the procedure. They also indicate that time spent waiting on standby should be reported with standby service E/M code The new guidelines further explain that cumulative one-on-one time spent in the operating room is used to determine the units of service for code It is possible that monitoring may begin prior to incision, for example, if positioning the patient on the operating table prior to incision is poses a risk to the patient. 76

77 EVALUATION & MANAGEMENT 77

78 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 ( ) have been established in the Evaluation and Management section to describe interprofessional telephone/ Internet consultative services. These codes are for reporting interprofessional telephone/internet consultation, which is defined in the guidelines as an assessment and management service in which a patient s treating physician or other qualified health care professional requests the opinion and/or treatment advice of a physician with specific specialty expertise (the consultant) to assist in the diagnosis and/or management of the patient s problem without the need for the patient s face-to-face contact with the consulting physician. 78

79 OTHER CHANGES TO E&M SECTION To conform with the CPT Nomenclature Reporting Neutrality initiative, the parenthetical note following code was revised to adhere to the policy of neutrality in identifying who may perform a procedure or a service. In addition, the parenthetical note was further clarified to address concurrent care services Year of parentheticals. Changes in almost every section providing clarification and guidance. 79

80 OTHER SECTION CHANGES Changes were made in every section of CPT. Those not covered in this presentation were due to parenthetical changes only. 80

81 Sources of information for this presentation CPT and RBRVS 2014 Symposium CPT 2014 Insider s View CPT Final Rule: Physician Fee Schedule 81