How Do CPT® Changes Stack Up for 2008?
Get ready for an above average year of code additions, deletions, and revisions.
By Michael Beebe, Director of CPT® at AMA and AAPC National Advisory Board member
It may look like an average CPT® manual with its familiar Concord grape and mustard cover, but the inside is a surprise this year. The code set coders use most is changing more than in many years, and it affects most AAPC members.
New and changed modifiers, altered and added evaluation and management (E/M) codes, and a spate of new Category II quality codes crown significant changes to all the chapters.
The CPT® code set for 2008 has 8,661 codes — this includes 244 new codes, 314 revised codes, and 50 deleted codes.
This amount of change is above average. For the past 15 years there has been an average of 210 additions and 205 revisions. These changes to the CPT® code set were the result of 174 code change proposals submitted to American Medical Association (AMA) staff, reviewed by CPT® Advisory Committee and AMA Health Care Professionals Advisory Committee advisors, and eventually acted on by the CPT® Editorial Panel.
That is not to say that every code change proposal results in new, revised, or deleted codes. It also does not mean the Panel only considers changes to CPT® codes. In addition to code level changes, the CPT® Editorial Panel also considers changes to section and subsection coding rules and parenthetic statements. These changes are not reflected in the code level statistics I just mentioned. With that being said, let’s take a look at some (but certainly not all) of the changes to the 2008 CPT® code set.
Note: You can learn more about the CPT® Editorial Panel process on the AMA website.
In response to the Physician Quality Reporting Initiative (PQRI), introduced by the Centers for Medicare & Medicaid Services (CMS), the largest number of changes in CPT® 2008 is in the Category II codes for performance measurement. This section of the book increased by 102 codes. In addition to adding new CPT® Category II codes in the book, the AMA is continually updating its internet with new performance measurement codes and measurement specifications from Appendix H of the CPT® book. CPT® Category III codes are also updated on the AMA’s internet site.
Specific coding changes by section of the CPT® codebook:
CPT® Guideline and Rule Changes
In conjunction with the development of an explicit, computer readable, CPT® hierarchy, numerous revisions and additions have been adopted in CPT® 2008. These changes provide a more meaningful and logical relationship between the section headings or subheadings and the codes that follow.
Changes made to the Instructions for Use section in the very front of the CPT® codebook include the addition of a new subsection for Results, Testing, Interpretation and Report. Previously, these instructions were in individual sections of the book. For CPT® 2008, the instructions are placed in the Introduction because the definition is relevant to all instances of these terms in the CPT® codebook. The definition is expanded to clarify the relationship and interpretation of the results to procedures that required interpretation of a technical component.
Evaluation and Management Changes
A new section was developed for Medical Team Conferences to describe team services by the physician and non-physician providers. Subheadings in the Preventive Medicine subsection were revised to encompass new codes that describe smoking cessation counseling and intervention and screening for alcohol and other substance abuse. As a follow-up to the addition of new codes to report Nursing Facility Services in 2006, these codes were revised with the addition of typical times for these services.
Medical team conferences include face-to-face participation by a minimum of three qualified health care professionals from different specialties or disciplines (each of whom provide direct care to the patient), with or without the presence of the patient, family member(s), community agencies, surrogate decision maker(s) (e.g., legal guardian), and/or caregiver(s). The participants are actively involved in the development, revision, coordination, and implementation of health care services needed by the patient. Reporting participants should have performed face-to-face evaluations or treatments of the patient, independent of any team conference, within the previous 60 days. Physicians may report their time spent in a team conference with the patient and/or family present using Evaluation and Management (E/M) codes (and time as the key controlling factor for code selection when counseling and/or coordination of care dominates the service). These introductory guidelines do not apply to services reported using E/M codes (see E/M services guidelines). However, the physician must be directly involved with the patient, providing face-to-face services outside of the conference visit with other providers or agencies.
Appendix E, the listing of the modifier 51 exempt codes, was refined through the CPT® editorial process. The CPT® Editorial Panel developed new modifier 51 criteria (the criteria list is included in the rationale provided for Appendix E in the 2008 CPT® book). Since modifier 51 exempt codes are typically reported with more extensive procedures or services (adjunctive to other procedures), there should be minimal pre- and post-service time (compared to the intraservice time) and minimal postoperative visits associated with the valuation of these procedures (refer to the AMA publication Medicare RBRVS: The Physicians’ Guide 2008 for information on service time and work relative values). Data obtained from the AMA/Specialty Society RVS Update Committee (RUC) was consulted to aid in evaluating services. The result is a significantly revised Appendix; and the deletion of the modifier 51 exempt status symbol “X” is indicated by inclusion of a revision symbol “p” on the revised codes.
The largest group of changes in the Surgery section are 68 musculoskeletal codes that clarify the appropriate separate reporting for external fixation when performed. For example, the hand and finger fracture or dislocation codes (26615, 26650, 26665, 26685, 26715, 26735, 26746, 26765, and 26785) are revised with removal of the terms “with or without” and “and or external,” and replaced with the phrase “includes internal fixation, when performed” to indicate that when external fixation is performed in addition to the listed procedures, it is reported separately For example, the new description for 26615 will read as follows: Open treatment of metacarpal fracture, single, includes internal fixation, when performed, each bone.
Users of CPT® 2008 will see this pattern repeated for many of the fracture and dislocation codes throughout the musculoskeletal section.
Code 20555 was established to report placement of needles or catheters into muscle and/or soft tissue for subsequent interstitial radioelement application. In addition, cross-references have been added to direct the user to codes for placement of needles or catheters into specific organ sites (breast [19296-19298], muscle or soft tissue of the head and neck , prostate , and pelvic organs or genitalia [except prostate] for interstitial radioelement application ). A cross-reference directing the user to the appropriate imaging procedures has also been added. Previously, CPT® contained no codes that describe surgical placement of needles or catheters for interstitial radioelement application for body sites other than prostate, breast, and bronchus.
Three add-on codes (20985, 20986, and 20987) were established to report computer navigation for musculoskeletal procedures. These codes are differentiated by lack of generation of an image (20985) and pre- (20987) and intra-operative (20986) use. Codes 20986 and 20987 are followed by instructional parenthetical notes that indicate these codes are reported one time only, regardless of the numbers of imaging modalities used to obtain the navigation information. Category III codes 0054T-0056T that previously reported these services were deleted.
Codes 22206-22208 were established to describe three-column osteotomy at the thoracic and lumbar levels. New guidelines have been added to clarify the osteotomy procedures and to define the three columns referred to in the code descriptors. Parenthetical notes were added to instruct users on the proper use of the new codes. The unit of service in codes 22206-22208 is one vertebral segment. Code 22206 is reported for three-column osteotomy when performed in the thoracic region of the spine. Code 22207 is reported when this procedure is performed in the lumbar region. Code 22208 is an add-on code and is reported for each additional vertebral segment with 22206 or 22207, depending on which region is involved.
Four codes (29904-29907) were established to report arthroscopic procedures of the subtalar joint. With advancements in scope technology, these procedures are examples of the ability to address smaller joints in the body, such as this joint between the talus and calcaneus in the hindfoot for such procedures as management of intra-articular fractures of the calcaneus and synovectomy for sinus tarsi syndrome. It is important to note that subtalar procedures are intended to report procedures of the joint between the talus and the calcaneus. For arthroscopic ankle procedures to address synovectomy, debridement, and arthrodesis of the tibiotalar and fibulotalar joints, codes 29894-29899 should be reported.
Three add-on codes (33257-33259) were established to enable reporting maze procedures. This revision creates a duplicate set of add-on codes to those established for the 2007 CPT® code set. In support of these revisions, the guidelines that addressed the restrictions related to the performance of maze procedures with other cardiac procedures were deleted. The guidelines were revised to include the new codes in the range of procedures in the instructions related to the inclusive procedures.
Code 33864 was established to report performance of root reconstruction in which the aortic valve is preserved and the aortic annulus is remodeled. This procedure is performed for treatment of aortic root diseases including reconstruction or remodeling of the ascending aorta while preserving the native aortic valve. All valve sparing aortic annulus reconstructions include valve suspension. The addition of this code reflects advancements in technique, technology, and patient population that no longer require a total root replacement include replacing the aortic valve (33863) and assists in differentiation of this procedure from the existing procedures described in the CPT® codebook for total root replacement or ascending aorta replacement with coronary reconstruction (33861).
Category III code 0153T was deleted and converted to Category I code 34806. Code 34806 was established to report the transcatheter placement of an implantable wireless pressure sensor (IWPS) located inside the body within the aneurysm sac, but outside the endovascular graft. Placement occurs during the endovascular repair (EVAR). Subsequent monitoring (separately reported by code 93982) of patients occurs after hospital discharge at yearly or half-yearly intervals, based on guidelines set forth by the Food and Drug Administration (FDA) for EVAR and individualized by patient status. Unlike computed tomography scanning, IWPS monitoring is completely noninvasive, uses no radiation, and does not require injection of iodinated contrast.
Three codes and related cross-references were established to report an open procedure for the excision, ablation, and/or destruction of peritoneal tumors differentiated according to the size of the largest tumor removed during a single session. The addition of codes 49203-49205 close a coding gap that existed and allow reporting treatment of ovarian and other malignancies when the primary organs (uterus, tubes, ovaries) were previously resected. Code 49203 is reported for the largest tumor measuring 5 cm in diameter or less; code 49204 is reported for the largest tumor measuring 5.1 cm to 10 cm in diameter; code 49205 is reported for the largest tumor with a diameter greatethan 10 cm.
Codes 58570-58573 were added to CPT® 2008 to report laparoscopic total hysterectomy, and are subdivided based on uterus weight and according to whether the tube(s) and/or ovary(s) are removed during the procedure. Prior to the 2008 codes, there was no mechanism in the CPT® code set for reporting a total hysterectomy performed laparoscopically — a procedure in which both the uterine cervix and body are completely detached from surrounding support structures via a laparoscopic approach, and in which the vaginal cuff is sutured via a laparoscopic approach.
The most significant revisions to the Radiology section of the CPT® code set for 2008 involve an effort to provide greater clarity regarding the intent of the original inclusion of the non-contrast imaging to describe early versions of the technology of computed tomography scanning.
CPT® codes 70496 and 70498 were revised editorially by substituting the phrases “without contrast material(s) followed by” and “and further sections,” with the phrase “non-contrast images, if performed.” This clarifies the original intent of these codes, which is not to require non-contrast imaging, but to include it when performed. This revision supports the lack of documentation for non-contrast CT imaging. The non-contrast imaging is used, for the most part, only for verification that the area of interest was captured in the area of the acquired anatomic imaging. For example, the new descriptor for 71275 will read as follows: Computed tomographic angiography, chest (noncoronary), with contrast material(s), including non-contrast images, if performed, and image post-processing changes.
New CPT® codes 75557-75564 were established to report the various combinations and permutations of imaging protocols with sufficient granularity for cardiac MR of the heart patterns and to more accurately
describe cardiac magnetic resonance imaging services as they are performed. In concert with the creation of 75557-75564, codes 75552-75556 were deleted.
Cardiac magnetic resonance (CMR) imaging technology has significantly changed since the original CPT® codes were established in 1993. At that time, the technology limited the procedure to a relatively few indications. Improvement in spatial and temporal resolution expanded the applications of CMR from a predominantly anatomic test to one that performs accurate physiologic evaluations. Because of this, CMR is unlike traditional MRI, which relies solely on static images to obtain clinical diagnoses. During a CMR examination, anatomical static images are coupled with moving functional images to provide a unique analysis of morphology and cardiac function. Additionally, a clinician can apply flow and velocity sequences, which now are more robust, to patients with valvular or congenital heart disease or vascular anomalies. The new codes describe cardiac MR studies that usually include a functional and morphologic assessment. Flow and velocity assessment is now alwaysperformed with a function and morphologic evaluation. Previously, contrast codes did not apply when functional assessment was performed.
Pathology and Laboratory Changes
For 2008, the Pathology and Laboratory section includes the addition of codes and cross-references to report a new metabolic panel; tests for cystatin C, human chorionic gonadotropin, and fecal calprotectin; and an immunology test for mononuclear cell antigen. Code revisions include modifications of the Coombs test, microdissection, and sperm analysis codes.
CPT® code 80047 was added to report a basic metabolic panel test that includes ionized calcium (82230). The existing panel code 80048 includes only a total calcium test in the listed series of tests. To support the addition of this code, code 80048 was revised with the addition of the phrase “calcium, total” in the panel description to differentiation from the 80047 code descriptor of “calcium, ionized.” An exclusionary parenthetical note was also added to preclude separately reporting code 80047 with code 80053 for the comprehensive metabolic panel. The new test panel provides clinical information similar to the traditional Basic panel, but is more commonly provided on testing platforms conducive to “point of care” utilization.
CPT® code 82272 was revised to clarify that this code is intended to describe testing for occult blood by peroxidase activity including from one to three simultaneous determinations. This code was also revised to clarify that it is performed for other than colorectal neoplasm screenings to differentiate this test from code 82270. The revisions to this code assist in clarifying its intent as a diagnostic test appropriately reported for use of a commonly available “three-test” card that is ordered for symptomatic reasons. The inclusion of “1-3” in the descriptor clarifies that this code is appropriately reported for assessment of either a single sample obtained from a digital rectal exam or for assessment of a three-test card prepared by the patient.
The most significant revisions to the Medicine section of the CPT® codebook for this year are in connection to the refinement of modifier 51 exempt status codes in Appendix E. These changes are most evident in the Immune Globulin, Vaccine, and Cardiac Catheterization sections.
New codes to this section include influenza vaccines, telephone and online assessments, subcutaneous infusion, cognitive performance testing, and ocular photoscreening. And guideline revisions to this section include revisions to clarify the reporting of electrocardiograms, infusion and chemotherapy infusion services, and cardiac catheterization contrast injections.
A new Telephone Services subsection (codes 98966-98968) and guidelines was added in response to changing consumer and health plan expectations for enhanced access to care, a new focus on chronic disease management, the need to reduce the costs of medical services, and advancements in use of technology by health care providers and patients. This will enable providers to report provision of telephone assessment and management services to patients in a non face-to-face manner.
Guidelines direct that these codes are intended to report services provided only by a qualified health care provider to the patient at the request of the patient. The patient is required to be an established patient. These codes are also used to report an episode of care initiated by a guardian of an established patient. If the telephone service ends with a decision to see the patient within 24 hours or next available urgent visit appointment, codes 98966-98968 are not reported. Rather, this telephone encounter is considered a part of the pre-service work of the subsequent assessment and management service, procedure, and visit. Similarly, if the telephone call refers to an assessment and management service performed and reported by the qualified health care provider within the previous seven days (either requested by the qualified health care provider or an unsolicited patient follow-up) or within the postoperative period of the previously completed procedure, then the services are considered part of the previous assessment and management service or procedure and should not be reported separately. An exclusionary parenthetical note was added that precludes reporting the telephone E/M codes 98966-98968 when another telephone or on-line E/M service was reported in the previous seven days.
The Panel also developed a new On-line Medical Evaluation subsection, code 98969, and guidelines were added to report provision of an on-line assessment and management service to patients in a non face-to-face manner. The guidelines direct that this code is intended to report services provided only by a qualified non-physician health care professional to the patient in response to the patient’s on-line inquiry. Many of the same conditions developed by the Panel for telephone service codes also apply to on-line evaluation service codes.
Keep Up The Good Work!
The changes to the CPT® code set for 2008 were not only a result of the CPT® Editorial Panel process, but also a result of the contributions of many different CPT® users from a variety of clinical and administrative settings. Although the CPT® Editorial Panel is responsible for all changes to the CPT® code set, the code change process is initiated by physicians, coders, researchers, payers and device/drug companies that see the need to add, revise or delete codes, parenthetic statements, and/or coding rules and guidelines. Please continue to work with the CPT® Editorial Panel process to improve the CPT® code set.
Our thanks to William A. Leaverton and the employees of the RR Donnelley printing plant in Menasha, Wis. for their hospitality in sharing with us the printing and binding process for the CPT® books.
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