CPT® 2017: Big Changes that Won’t Put You to Sleep

Updates to conscious sedation, telemedicine, laryngoplasty, and other codes will keep you on your toes.

A single policy change has affected the valuation and application of nearly 450 codes in CPT® 2017. Let’s explore the impact of this change, as well as the other major changes in CPT® 2017.

Conscious Sedation Is No Longer Bundled

The change with the most far-reaching effect is that CPT® no longer defines conscious sedation as an inherent part of any procedure. Both Appendix G, which listed all codes that included conscious sedation, and the “bull’s-eye” symbol that indicated a code’s inclusion of moderate (conscious) sedation, are removed from CPT® 2017. Prior codes describing conscious sedation (99143-99150) are deleted and replaced with new codes (99151-99157).
As the Centers for Medicare & Medicaid Services (CMS) explained in the 2015 Physician Fee Schedule Proposed Rule, many codes valued to include conscious sedation were reported instead with a separate anesthesia code (as allowed by CPT® guidelines). In other words, rather than administer conscious sedation (which was included in, and paid for as part of, the primary procedure), providers performed a separately reimbursable anesthesia service.
For 2017, codes previously valued to include conscious sedation (when performed) are revalued to no longer include conscious sedation. This change will allow providers to separately report conscious sedation, when performed and properly documented, with more accuracy. Per the 2017 Physician Fee Schedule Final Rule, “This coding change [provides] for payment for moderate sedation services only in cases where it is furnished.”
Six new codes report moderate sedation according to patient age and the timed duration of the service:
99151 Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status; initial 15 minutes of intraservice time, patient younger than 5 years of age
99152 initial 15 minutes of intraservice time, patient age 5 years or older
+99153 each additional 15 minutes intraservice time (List separately in addition to code for primary service)
99155 Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; initial 15 minutes of intraservice time, patient younger than 5 years of age
99156 initial 15 minutes of intraservice time, patient age 5 years or older
+99157 each additional 15 minutes intraservice time (List separately in addition to code for primary service)
For 2017, CMS is augmenting the new moderate sedation CPT® codes with an endoscopy-specific moderate sedation code, and adjusting the valuation to reflect the differences in physician survey data between gastroenterology and other specialties.
Report HCPCS Level II code G0500 (instead of 99152) when moderate sedation services are furnished by the same practitioner reporting the endoscopy procedure.
G0500 Moderate sedation services provided by the same physician or other qualified health care professional performing a gastrointestinal endoscopic service that sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status; initial 15 minutes of intra-service time; patient age 5 years or older (additional time may be reported with 99153, as appropriate)
A total of 441 (mostly endoscopic) codes no longer include moderate sedation, with no further changes to the code descriptors. Two codes (92978 and 92979, which describe endoluminal imaging of coronary vessel or graft) no longer bundle moderate sedation, but also include additional descriptor changes.

CPT® Embraces Telemedicine

Telemedicine uses technology to allow healthcare professionals to provide clinical healthcare from a distance. It helps to eliminate distance barriers and can improve access to medical services that may not be available consistently in rural communities. For 2017, CPT® introduces a modifier specifically to identify telemedicine services: Modifier 95 Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunication system.
This modifier may be appended to 79 designated codes (primarily evaluation and management (E/M) services and medicine codes, plus several Category III codes) to describe a service that involves “real-time interaction between a physician or other qualified health care professional and a patient who is located at a distant site from the physician or other qualified health care professional,” per CPT® instructions. If the telemedicine service is not performed real-time with the patient, modifier 95 is not appropriate.
The interactive telecommunications equipment must include, at a minimum, audio and video: The patient and provider must be able to communicate and interact in real time (e.g., the service mimics a face-to-face visit, although the provider and patient are distant from one another). Services reported must meet all minimum code requirements. CPT® instructs, “The totality of the communication of information exchanged between the physician or other qualified health care professional and the patient during the course of the synchronous telemedicine service must be of an amount and nature that would be sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction.”
Services for which modifier 95 may be appended are designated in the CPT® codebook with a “star” symbol, and are listed in CPT® Appendix P — CPT Codes That May Be Used for Synchronous Telemedicine Services (both the star symbol and Appendix P are new to CPT® 2017).

Medicine Codes Replace Health Assessment E/M

Aside from telemedicine service indicator, the sole change to the E/M portion of CPT® 2017 is the deletion of 99420. In its place, two new medicine codes describe health risk assessments, either for a patient (96160) or a patient caregiver (96161), for the benefit of the patient. The instruments used must be standardized and scorable.
Code 96161 is appropriate for maternal depression screening. For example, if the mother is the patient and depression is suspected, report 96160. If the encounter is focused on the baby, and concerns about maternal depression leads to a postpartum depression screening, report 96161.

Spinal Instrumentation Gets an Update

To differentiate among intervertebral biomechanical devices (and thereby increase coding precision), 22851 is deleted and replaced by three, more precise add-on codes to describe biomechanical devices placed in the intervertebral disc space (with and without arthrodesis, 22853 and 22859, respectively), or attached to vertebral bodies (22854).
Also new in this section, 22867-22870 describe interlaminar/interspinous process stabilization/distraction devices, marketed under several brand names (e.g., X STOP®, NuVasive®), which are implanted to treat the symptoms of spinal stenosis (pain, cramping and muscle weakness, etc.), and which may be performed with or without open decompression or fusion. The device is implanted between the vertebral spinous processes and is opened or expanded to distract (open) the neural foramen and decompress the nerves.

Laryngoplasty-palooza

There’s a lot of action in the laryngoplasty codes. Code 31582 is deleted and replaced by four new codes (31551-31554), each describing laryngoplasty for laryngeal stenosis (congenital or acquired narrowing of the airway) by one of several methods.
Code 31591 Laryngoplasty, medialization, unilateral describes a procedure to alleviate vocal cord weakness or paralysis. The surgeon creates a window in the thyroid cartilage and places a small implant to move the affected vocal fold and hold it in place, so the functioning vocal fold can close as necessary for normal voice and swallowing. This is a unilateral procedure (e.g., for one vocal fold).
Code 31592 Cricotracheal resection now reports excision of a portion of the airway just below the larynx (most commonly to treat stenosis). The larynx and trachea are sewn back together.

Varicose Vein Options Expand

Endovenous ablation therapy is performed to eliminate varicose veins, which are incompetent veins typically visible just below the surface the legs and feet. New codes 36473 and +36474 involve a combination of mechanical and chemical methods to ablate the veins. An intraluminal device is used to disrupt blood flow and “scratch” the interior surface of a vein into which medication is then infused. CPT® provides additional instruction for coding catheter injection of sclerosant without endovascular mechanical disruption of the vein intima, and for catheter injection of an adhesive.

New Dialysis Circuit Codes

CPT® 2017 introduces nine new codes (36901-36909) under the added subhead Dialysis Circuit, along with several pages of definitions and instructions to apply the new codes properly. The dialysis circuit is created to allow easy, repeated access to blood vessels to perform hemodialysis (removing blood from the patient’s body, cleansing it to replace/supplement the function of the kidneys, and returning it to the patient’s body). CPT® separates the dialysis circuit into two components: The peripheral dialysis segment and the central dialysis segment. Both are defined within the instructions provided under the Dialysis Circuit subhead.
The dialysis circuit codes roughly describe a hierarchy of services, with 36901 Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s), injection(s) of contrast, all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava, fluoroscopic guidance, radiological supervision and interpretation and image documentation and report describing imaging of the dialysis circuit. Code 36902 describes the same service, with the addition of transluminal balloon angioplasty of the peripheral dialysis segment; 36903 describes all the services in 36902, plus transcatheter placement of intravascular stent(s) in the peripheral dialysis segment with all necessary imaging and radiological supervision and interpretation (S&I). Other codes in this group describe transluminal mechanical thrombectomy and/or infusion to treat any/all thrombus without (36904) and with balloon angioplasty (36905) and transcatheter intravascular stent placement (36906). Add-on codes describe angioplasty of the central dialysis segment (36907), stenting in the central dialysis segment (36908), and permanent vascular embolization or occlusion in the dialysis circuit (36909).

Transluminal Balloon Angioplasty
Adds Radiological S&I

CPT® 2017 deletes eight codes to report transluminal balloon angioplasty, plus the related radiological S&I codes, and replaces them with four new codes (37246-37249) that simplify reporting. Each of the new codes includes all necessary imaging and radiological S&I.

Spinal Injections Distinguish with/without Imaging

CPT® 2017 introduces a series of codes (62320-62327) to better differentiate epidural or subarachnoid injections performed with and without imaging guidance, by spinal region (e.g., 62324 Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance [emphasis added]). This new series replaces deleted codes 62310-62319.
Radiology
Fluoroscopic guidance for needle placement (77002) becomes a specified add-on code for 2017, as does fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (77003). CPT® parenthetical instructions provide a full listing of primary codes with which you may report +77002 and +77003.
Mammography codes are overhauled and condensed — three codes instead of five — to simplify reporting. Each of the three new codes includes computer-aided detection (CAD) to aid in detecting breast cancer:
77065 Diagnostic mammography, including computer-aided detection (CAD) when performed; unilateral
77066 bilateral
77067 Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed

Pathology and Laboratory

New codes to report presumptive drug class screening (80305-80307) are selected based on the method used to perform the test(s). Each of the new codes may be reported once, per test, regardless of the number of drug classes tested. New guidelines in this section provide coding guidance.
New codes 81413 and 81414 report genomic sequence analysis of at least 10 or two genes, respectively. The test helps to identify cardiac conditions such as Brugada syndrome, long QT syndrome, short QT syndrome, and catecholaminergic polymorphic ventricular tachycardia.
Code 81422 now reports genomic sequence analysis for fetal chromosomal microdeletions, and a unique code (87483) is added to identify central nervous system infections.

Medicine Sees Many Refinements, Few New Codes

Vaccines, Toxoids – Nine influenza vaccine codes are revised and are now reported by dosage, not patient age. For example, the descriptor for 90686 Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.5 mL dosage, for intramuscular use eliminates the requirement “when administered to individuals 3 years and older” and adds “0.5 mL dosage.” Code 90674 is added to improve reporting of quadrivalent (e.g., Flucelvax®) versus trivalent (90661) vaccine. The dosage is 0.5 mL, by intramuscular injection.
Psychotherapy – CPT® adds introductory text to the Psychotherapy section, and now classifies 90832-90838 as “psychotherapy for the individual patient, although times are face-to-face services with patient and may include informant(s). Patient must be present for all or majority of the service.” As such, the phrase “and/or family member” is removed from the code descriptors. Look to codes 90846 and 90847 when “utilizing family psychotherapy techniques such as focusing on family dynamics.” Do not report 90846 or 90847 for services of less than 26 minutes.
Cardiovascular – The descriptors for add-on codes 92978 and 92979 are revised to expand their use to include optical coherence tomography, in addition to intravascular ultrasound (IVUS), as a means to image a coronary vessel or graft. Report one unit of either code, per session, for the initial vessel targeted. CPT® includes a list of allowable primary procedure codes with which you must report +92978 and +92979.
Three new codes are added to describe repair of paravalvular leak. A paravalvular leak occurs at the annulus of a replacement valve:

• 93590 describes placement of an initial occlusion device (plug) to block a leak at the mitral valve, using a catheter;
• 93591 describes placement of an initial occlusion device (plug) to block a leak at the aortic valve, using a catheter; and
• +93592 describes placement of each additional plug beyond the initial occlusion device to block a leak at the aortic or mitral valve, using a catheter.

Previously, these procedures would have been reported using an unlisted procedure code.
Hydration, Therapeutic, Prophylactic, Diagnostic Injections and Infusions, and Chemotherapy and Other Highly Complex Drug or Highly Complex Biologic Agent Administration – New code 96377 reports application of on-body injectors (e.g., OnPro®), including cannula insertion. The system automatically provides timed injections (for example, for oncology patients requiring chemotherapy injections).
Physical Medicine and Rehabilitation – Physical therapy, occupational therapy, and athletic training evaluation codes are all new this year, as discussed in November’s Healthcare Business Monthly, (pages 28-29). The new, time-based codes (97161-97172) are similar to E/M codes found in the 99000 series, but are specific to therapy.
On a final note, 97602 (removal of devitalized tissue from wound(s), non-selective debridement, without anesthesia) is revised to include larval therapy, also known as maggot debridement therapy, to remove dead tissue from non-healing soft tissue wounds. Disinfected fly larvae are introduced to the wound. A special dressing is used to keep the maggots from escaping, while allowing sufficient oxygen for their survival.
Note: Information on new and revised Category III codes will be covered in a separate, upcoming article.
Resources
CMS, CY 2015 Physician Fee Schedule Proposed Rule
CMS, 2017 Physician Fee Schedule Final Rule

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Rae Jimenez

Raemarie Jimenez, CPC, CIC, CPB, CPMA, CPPM, CPC-I, CDEO, CANPC, CRHC, CCS, is senior vice president of products at AAPC and a member of the Salt Lake City, Utah, local chapter.

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