CPT® 2009: Eyes Upon Change

By Marie L. Mindeman, BA, RHIT, director of CPT® Coding and Regulatory Services, American Medical Association

Code revisions for CPT® 2009 follow an interesting trend of large-scale changes in smaller sections of the book, similar to the infusion codes that were established in CPT® 2006. For 2009, there are 15 renumbered codes and two new codes in a new subsection for pediatric services in the Evaluation and Management (E/M) section. The remaining groups with significant changes are in the Medicine section, with eight deleted codes and  20 new codes for dialysis services; 13 revised codes, 23 new codes, and 13 deleted codes for cardiovascular monitoring; and a complete re-numbering and deletion of the non-chemotherapy/complex infusion services codes to establish joint guidelines for both infusion codes sets.

Evaluation and Management – CEMC

Evaluation and Management

The E/M services section includes extensive revisions of all pediatric E/M services, with renumbering of all the codes to a new subsection. These revisions include the Pediatric Patient Transport, Inpatient Neonatal and Pediatric Critical Care Services and Newborn Care Services sections. The pediatric services codes are combined and simplified and now appear as an aggregate of services with guidelines applied to the entire series of codes. Two new services are added to the previously existing range of services, with the addition of codes 99475 Initial inpatient pediatric crucial care, per day, for the evaluation and amagement of a critically ill infant or young child, 2 through 5 years of age and 99476 Subsequent inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 2 through 5 years of age to report inpatient critical care management of children aged two through five years. Renumbering of the pediatric services codes also resulted in numerous revisions of the Critical Care Services guidelines to accommodate the new cross-references and guidelines.

Revisions to the face-to-face prolonged services codes 99354-99357 clarify that these codes are for reporting only with other time-based E/M services. In addition to these changes, modifier 21 is deleted, since it provided a duplicate mechanism for reporting prolonged services.

Anesthesia

Anesthesia section revisions are minimal and focus on clarification of populations described by the anesthesia services for coronary artery bypass graft procedures reported with code 00562 Anesthesia for procedures on heart, pericardial sac, and great vessels of chest; with pump oxygenator, age 1 year or older, for all non-coronary bypass procedures (eg, valve procedures) or for re-operation for coronary bypass more than 1 month after original operation and new code 00567 Anesthesia for direct coronary artery bypass grafting; with pump oxygenator. A new code is also established for anesthesia services specific to evacuation of a hematoma via the craniectomy/craniotomy approach.

Surgery

Changes to this section include many revisions of the Integumentary System codes and the Skin Replacement guidelines to clarify spatial references within the code descriptors. The phrase “or part thereof” is added to the descriptors for 10 add-on codes to clarify that their use is to report any portion of additional measurement performed in the procedure. Code 19296 Placement of radiotherapy afterloading expandable catheter (single or multichannel) into the breast for interstitial radioelement application following partial mastectomy, includes imaging guidance; on date separate from partial mastectomy for placement of a catheter prior to interstitial radioelement application is also revised to more broadly describe new catheter technology.

New codes are added in the Musculoskeletal section for the spine and pelvis, with revisions of codes in the hip, shoulder, and femur. The musculoskeletal computer-assisted navigational procedures that were established for CPT® 2008 are deleted and reinstated as Category III codes 0054T and 0055T pending further demonstration of wide spread use for these services. A new symbol is added to the Category III section to accommodate this new action for CPT®. Three new codes, 22856, 22861, and 22864, are converted from Category III codes 0090T, 0093T, and 0096T to report performance of cervical artificial disc arthroplasties.

Other new codes include non-coronary bypass graft procedures for treatment of atherosclerosis, tongue base reductions, pancreatic duct cannulation, esophageal repair, laparoscopic hernia repairs, and cranial and spinal stereotactic radiosurgery. Other important code additions include clarification of the hemorrhoid destruction, prostate resection codes, nerve injection and keratoplasty codes.

Two new vein non-coronary bypass graft codes, 35535 Bypass graft, with vein; hepatorenal and 35570 Bypass graft, with vein; tibial-tibial, peroneal-tibial, or tibial/peroneal trunk-tibial, are added for hepatorenal and lower extremity tibial bypass grafts. Three additional prosthetic graft codes are added to report performance of ileoceliac, iliomesenteric, and iliorenal bypasses. Two new codes for tongue base surgical treatments for obstructive sleep apnea include code 41512 Tongue base suspension, permanent suture technique for tongue base suspension via suture and 41530 Submucosal ablation of the tongue base, radiofrequency, one or more sites, per session for submucosal ablation and reduction of tongue base tissue. An add-on code 43273 Endoscopic cannulation of papilla with direct visualization of common bile duct(s) and/or pancreatic duct(s) (List separately in addition to code(s) for primary procedure) is established for direct visualization of the common bile and pancreatic ducts, for use with other codes, as listed in the endoscopic retrograde cholangiopancreatography (ERCP) series of codes.

Two new subsections and guidelines are added with the deletion of code 61793 for stereotactic radiosurgery. The new sections and guidelines provide a more granular method of describing the services previously reported with 61793 for spinal and cranial stereotactic radiosurgery, with instructions to separate the surgical components of these services from the services provided by the radiation oncologist. The new cranial codes distinguish the radiosurgery services for simple (codes 61796 and 61797) vs. complex (codes 61798 and 61799). Regardless of the number of sessions required, the codes in the cranial and spinal subsections are reported only once per lesion per course of treatment.

The series of prostate resection codes is revised with the deletion of codes 52606, 52612, 52614, and 52620. The services previously reported with codes 52612, 52614, and 52620 are now reported with code 52601 Transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete (vasectomy, meatomy, cystourethroscopy, urethral calibraton and/or dilation, and internal urthrotomy are included). Transurethral fulguration for post-operative bleeding, reported previously with code 52606 is now reported only with the cystourethroscopic code 52214 Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) of trigone, bladder neck prostatic fossa, urethra, or periurethral glands. The nerve injection codes 64416-64449 are revised with the deletion of “including daily management for anesthetic agent administration” to reflect the change in the typical site, from inpatient to outpatient, in which this service is typically provided.

Two new codes are added to specifically report injection to the plantar common digital nerve. These services are provided for inflammation of the plantar nerve, including Morton’s neuroma. CPT® code 64455 Injection(s), anesthetic agent and/or steroid, plantar common digital nerve(s) (eg, Morton’s neuroma) is reported for injection of anesthetic agent and code 64632 is reported for destruction of the plantar nerve.

Radiology

The revisions of the Radiology section are minimal and include deletion and addition of new codes for high dose rate brachytherapy to adjust the nomenclature to reflect technology changes. New codes 77785-77787 now describe the procedure according to the number of channels rather than “dwell” catheters. Code 78808 Injection procedure for radiopharmaceutical localization by non-imaging probe study, intravenous (eg, parathyroid adenoma) was added for injection of a diagnostic radiopharmaceutical for localization with non-imaging gamma probes.

Pathology and Laboratory

Most notable of the revisions in the Pathology and Laboratory section for this year is a new subsection and three new codes for In-Vivo point-of-care tests and deletion of the Transcutaneous test subsection. This new section for point-of-care tests includes the addition of codes for transcutaneous tests for bilirubin (88720), carboxyhemoglobin, (88740), and methemoglobin (88741). The transcutaneous bilirubin test was previously reported with deleted code 88400. Existing hemoglobin testing codes 82375 Carboxhemoglobin; quantitative and 82376 Carboxhemoglobin; qualitative are revised for consistency in nomenclature with the transcutaneous test descriptors.

Other new codes are added to report detection of non-viral enzymatic activity, coagulation, and des-gamma-carboxy-prothrombin. The molecular diagnostic testing codes are revised to specify frequency or quantity when reporting.

Medicine

A large number of the revisions for the CPT® 2009 codebook take place in the Medicine section. Revisions include deletion and renumbering of entire code sections, including the therapeutic and hydration infusion codes and the hemodialysis codes for home and outpatient hemodialysis.

Infusion code revisions address comments from users who indicated the geographic separation of these codes in the book resulted in confusion in the relationship of the hydration and therapeutic infusion codes to the chemotherapy and other complex infusion codes. To address these concerns, the hydration and therapeutic infusion codes are deleted and renumbered to codes 96360-96379, to immediately precede the 96400 chemotherapy and other complex infusion codes. This relocation allowed for simplification of the guidelines, with creation of an overarching set of guidelines for the entire infusion service section and repetitious information removal. The description of chemotherapy codes is also revised with addition of the phrase “or other highly complex drug or highly complex biologic agent” in multiple locations. This text addition stresses that the codes in the 96400 series are not based upon particular drug use, but upon the provider’s increased effort due to an increased risk of severe patient reaction.

The addition of new codes to the hemodialysis section provides consistency with HCPCS Level II ‘G’ codes in describing the face-to-face physician services for management of the patient’s condition. The codes distinguish the age of the patient and the site of service. The changes include the addition of 12 codes (90951-90962) to report full month outpatient end-stage renal disease (ESRD) related services based upon the number of face-to-face encounters provided.

Four new codes (90963-90966) are added for full month home ESRD related services. Codes 90967-90970 are added to report hemodialysis services provided over less than a full month, distinguished only by age, and regardless of the setting in which the services were provided.

The Cardiovascular subsection also includes large changes, including extensive guideline and code additions and revisions of the Echocardiography section.

In the cardiology section, extensive revisions were made to most of the codes and a new subsection with extensive guidelines and many codes to report cardiac device monitoring was added. The codes previously describing electronic analysis of various cardiovascular systems (loop recorders, pacemakers, cardioverter-defibrillators) in the noninvasive physiologic procedures section (93727-93736; 93741-93745) were deleted. Two new categories of cardiovascular device monitoring services were added. The first type of services describes wearable mobile services and the second type describes device evaluations. In the wearable section, codes 93228 Wearable mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events transmitted to a remote attended surveillance center for up to 30 days; physician review and interpretation with report and subordinate code 93229 technical support for connectionand patient instructions for use, attended surveillance analysis and physician prescribed transmission of daily and emergent data reports were added to the mobile telemetry series of codes to report a 30-day service differentiated by reporting the physician review and interpretation or the technical support for connection, patient instructions, and surveillance.

Codes 93224-93227, 93230-93237, and 93268-93272 were editorially revised to specify the nomenclature for wearable, mobile telemetry. Codes 93279-93299 (21 new codes) and their associated guidelines were added to report provision of diagnostic medical procedures using in-person and remote technology to evaluate device therapy and cardiovascular physiologic data. These codes are now separated into seven new codes for in-person programming device evaluation (93279-93285); two new codes for peri-procedural device evaluation (93286-93287); and 11 codes for in person (93288-93292) and remote (93294-93299) interrogation device evaluation. Code 93293 Transtelephonic rhythm strip pacemaker evaluation(s) single, dual, or multiple lead pacemaker system, includes recording with and without magnet application with physician analysis, review and report(s), up to 90 days is added for transtelephonic strip pacemaker evaluation.

Revisions to Echocardiography codes include new guidelines and definitions for echocardiography studies. Code 93307 is revised with emphasis for reporting a complete study that excludes spectral or color Doppler study. Code 93306 is added as a comprehensive service to include the spectral or color flow Doppler studies. Codes 93308 and 93350 are revised for consistency with current CPT® nomenclature to indicate “includes M-mode recording, when performed.”

The echocardiography/stress studies codes are also revised with the addition of a comprehensive code, 93351, to report the combined service of stress echocardiography and a complete stress test. A single provider in the non-facility setting performs this service. Previously, this service was reported with both codes 93350 and 93015. Add-on code 93352 now reports the injection of contrast agent during a stress echo examination.

Category II

The Category II section of the book continues to be the fastest growing section of CPT®, with the addition of 150 codes for physician quality reporting improvement (PQRI) measures, eight new clinical conditions, and the addition of a new subsection for structural measures.

Category III

The Category III section gets 13 new codes and loses 22 codes, demonstrating the dynamic and transitional nature of this emerging technology and services code category. Of the code deletions, seven codes are converted to Category I codes, including the codes for reporting programming and analysis of gastric neurostimulators, template guided saturation prostate biopsies, cervical artificial disc arthroplasty, and actigraphy testing. The remaining 15 deleted Category III codes are sunset, without meeting the criteria for conversion to Category I codes.

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