CPT 2018: E/M Aligns with Quality Care Initiatives

Code changes affect nearly every specialty.

CPT® 2018 introduces over 350 new Category I and III codes changes, as well as revised introductory guidelines, and new and revised parenthetical references.
Two areas that have been consistently misinterpreted in the past are revised for more concise coding: (1) international normalized ration (INR) monitoring and education; and (2) bone marrow aspirations and biopsies. Also for 2018, you’ll see a trend for new care management in evaluation and management (E/M) services to align with quality care initiatives. Medical advancements called for many new codes in the Pathology and Laboratory section, and in the Surgery/Cardiovascular System section.
Here’s a summary of the most significant changes.

Observation Clarified

CPT® 2018 adds the term “outpatient hospital” to the descriptor of observation codes 99217-99220 to clarify that observation is specific to outpatient status (place of service 22). Do not report observation services for a patient admitted to the hospital.

Assessment for Cognitive Impairment

CPT® 99483, which replaces HCPCS Level II G0505, reports assessment of and care planning for a patient with cognitive impairment. To report this service, all 10 bulleted items listed in the code descriptor must be performed and documented. If all bulleted items are not performed, you must select an appropriate E/M code based on documentation. The service may be reported for new or established patients, but not with other E/M services. You may report cognitive assessment and care planning as frequently as once per 180 days, per CPT® (Remember: Payer policy may say otherwise).

New Codes for Collaborative Care Management

Three new, time-based codes report psychiatric collaborative care management (CoCM):
99492 Initial psychiatric collaborative care management, first 70 minutes in the first calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional
99493 Subsequent psychiatric collaborative care management, first 60 minutes in a subsequent month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional
+99494 Initial or subsequent psychiatric collaborative care management, each additional 30 minutes in a calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional (List separately in addition to code for primary procedure)
Per the American Psychiatric Association, psychiatric CoCM services:

… typically [are] provided by a primary care team consisting of a primary care physician and a care manager who work in collaboration with a psychiatric consultant, such as a psychiatrist. Care is directed by the primary care team and includes structured care management with regular assessments of clinical status using validated tools and modification of treatment as appropriate. The psychiatric consultant provides regular consultations to the primary care team to review the clinical status and care of patients and to make recommendations.

Code 99492 replaces HCPCS Level II code G0502; 99493 replaces G0503; and 99494 replaces G0504.

New Code for Behavioral Health Integration Services

New code 99484 Care management services for behavioral health conditions, at least 20 minutes of clinical staff time, directed by a physician or other qualified health care professional, per calendar month replaces HCPCS Level II code G0507 to report general behavioral health integration services, which incorporates principles associated with collaborative care. To report these services, all bulleted items listed in the full code descriptor must be performed and documented, and the time threshold (in this case, at least 20 minutes of clinical staff time, directed by a physician or other qualified healthcare professional, per month) must be met.

Anesthesia Revises Gastro and
Lower Endoscopic Services

Within the anesthesia section, several codes for endoscopic upper and lower gastrointestinal procedures are deleted and replaced by new codes that improve reporting specificity. For example, 00740 Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum is deleted, and replaced by two new codes:
00731 Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum; not otherwise specified
00732 endoscopic retrograde cholangiopancreatography (ERCP)
Similar new codes are introduced for lower intestinal endoscopic procedures (00811, 00812) and combined upper and lower endoscopic procedures (00813).

Integumentary

Two new codes report flaps:
15730 Midface flap (ie, zygomaticofacial flap) with preservation of vascular pedicle(s)
15733 Muscle, myocutaneous, or fasciocutaneous flap; head and neck with named vascular pedicle (ie, buccinators, genioglossus, temporalis, masseter, sternocleidomastoid, levator scapulae)
Code +19294 Preparation of tumor cavity, with placement of a radiation therapy applicator for intraoperative radiation therapy (IORT) concurrent with partial mastectomy (List separately in addition to code for primary procedure) is added to report preparation of a tumor cavity and placement of a radiation therapy applicator for intraoperative radiation therapy. Report this add-on code in addition to partial mastectomy procedures (19301, 19302).

Musculoskeletal

The sole new code in the musculoskeletal portion of CPT® 2018, +20939 Bone marrow aspiration for bone grafting, spine surgery only, through separate skin or fascial incision (List separately in addition to code for primary procedure), reports bone marrow aspiration through separate incision for spine surgery. Report this add-on code in addition to the primary spinal surgery code.

Respiratory Changes Focus on Nasal/Sinus Endoscopy

Three new codes describe procedures performed at the same time as nasal/sinus endoscopy with total ethmoidectomy (removal of tissue from anterior and posterior ethmoid sinus):
31253 Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including frontal sinus exploration, with removal of tissue from frontal sinus, when performed
31257     total (anterior and posterior), including sphenoidotomy
31259     total (anterior and posterior), including sphenoidotomy, with removal of tissue from the sphenoid sinus
These new codes combine services reported by existing codes for procedures performed at the same time on the same (ipsilateral) side.
New code 31241 Nasal/sinus endoscopy, surgical; with ligation of sphenopalatine artery reports ligation of the sphenopalatine artery during a nasal/sinus endoscopy. Previously, this service was reported using an unlisted procedure code (e.g., 30999).
Code 32994 Ablation therapy for reduction or eradication of 1 or more pulmonary tumor(s) including pleura or chest wall when involved by tumor extension, percutaneous, including imaging guidance when performed, unilateral; cryoablation is added to differentiate cryoablation of pulmonary tumors from radiofrequency ablation therapy (reported with revised code 32998 Ablation therapy for reduction or eradication of 1 or more pulmonary tumor(s) including pleura or chest wall when involved by tumor extension, percutaneous, radiofrequency including imaging guidance when performed, unilateral; radiofrequency).

New Codes for Artificial Heart Procedures

New Category I codes 33927-33929 replace Category III codes (0051T-0053T) for services related to total heart replacement.

EVAR Codes Are a Significant Addition

The largest grouping of new codes (34701-34716) in CPT® 2018 report services related to endovascular abdominal aortic repair (EVAR). The procedures include determining the correct size and type of endograft to be used, deployment of the endograft, non-selective catheter placement, radiological supervision and interpretation (S&I), and angioplasty at the endograft site. CPT® includes a new section header and extensive parenthetical instructions to aid in the use of these codes.
With the introduction of the new codes, previous codes for endovascular repair of infrarenal abdominal aortic aneurysm (e.g., 34800 and others) are deleted, as are the associated radiology codes (e.g., 75952 Endovascular repair of infrarenal abdominal aortic aneurysm or dissection, radiological supervision and interpretation).

Other Cardiology Changes

Codes 34833 and 34834 are revised to indicate the purpose of these procedures is delivery of endovascular prosthesis.
New codes 36465 and 36466 describe injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring, for a single incompetent extremity truncal vein; or for multiple incompetent truncal veins in the same leg, respectively.
Two new codes (36482 and 36483) similarly describe endovenous ablation therapy of incompetent vein. During the procedure, a catheter is positioned in the full length of the incompetent vein and the adhesive is administered remote from the access site to collapse the vein.

Bone Marrow Aspiration Now Selected by Purpose

A significant change in CPT® 2018 is that bone marrow aspiration codes are selected according to their purpose. For example, when coding bone marrow aspiration for spine surgery performed through a separate incision, select the new add-on code 20939
(see the Musculoskeletal section above). For diagnostic bone
marrow aspiration, report revised code 38220; for biopsy, report 38221. When an aspiration is both diagnostic and a biopsy, report 38222.

Esophagectomy

Several new and revised codes report esophagectomy:
43286 describes an esophagectomy using a laparoscopic mobilization and pyloric drainage in combination of the open approach for a cervical pharyngogastrostomy or esophagogastrostomy.
43287 describes an esophagectomy of the distal two-thirds using a laparoscopic mobilization and pyloric drainage, with separate thoracoscopic mobilization of the esophagus and thoracic esophagogastrostomy.
43288 describes an esophagectomy with thoracoscopic mobilization of the esophagus, laparoscopic proximal gastrectomy, pyloric drainage, and an open cervical pharyngogastrostomy or esophagogastrostomy.

SpaceOAR® Gets a Category I Code

Code 55874 replaces Category III code 0438T to describe placement of a temporary, biodegradable implant, marketed as the SpaceOAR® System, used to reduce rectal injury in men receiving prostate cancer radiation therapy. The implant is placed via needle, and placement includes imaging guidance.

New Total Hysterectomy Code

Code 58575 is introduced to report extensive laparoscopic surgeries for gynecological cancers. The service includes a total hysterectomy for tumor debulking, omentectomy, and salpingo-oophorectomy, when performed.

Nerve Repair with Allograft
No Longer an Unlisted Procedure

New codes report nerve allograft: 64912 reports each nerve that is repaired using the first strand. If additional strands are used, report +64913. Previously, nerve allograft repair was reported with unlisted code 64999.

Chest, Abdomen X-ray Now
Reported by Number of Views

Codes for chest and abdomen radiologic exam are totally revised. Previous codes are deleted and replaced by new codes that specify the number of views taken. For example:
71045 Radiologic examination, chest; single view
71046 2 views
71047 3 views
71048 4 or more views
74018 Radiologic examination, abdomen; 1 view
74019 2 views
74021 3 or more views

Pathology and Laboratory

New codes report the analysis of ASXL1, which are frequently mutated genes in malignant myeloid diseases; 81175 reports the full gene sequence test and 81176 reports the targeted sequence analysis test.
Levels 1, 2, and 4-7 molecular pathology codes are revised to exclude dozens of specific procedures reported using new codes. For example, four new codes (81361-81364) report the gene analysis of HBB (hemoglobin, subunit beta). Those tests previously were reported with Tier 2 code 81401.
New code 86794 Zika virus, IgM reports the test used to identify antibody testing for immunoglobulin M (IgM) for Zika virus. Similarly new are 87634 Infectious agent detection by nucleic acid (DNA or RNA); respiratory syncytial virus, amplified probe technique for respiratory syncytial virus detection performed via detection of the infectious agent, and 87662 Infectious agent detection by nucleic acid (DNA or RNA); Zika virus, amplified probe technique for Zika virus detection performed via detection of the infectious agent.

PLA Codes Are an All-new Addition

Proprietary laboratory analyses (PLA) codes 0001U-0017U are a new addition to the CPT® code set approved by the American Medical Association CPT® Editorial Panel. They are alphanumeric codes with a corresponding descriptor for labs or manufacturers that want to identify their test more specifically. Tests with PLA codes must be performed on human specimens, and must be requested by the clinical laboratory or the manufacturer that offers the test.

New Vaccines

Several new vaccine codes are introduced. Code 90756 reports a new influenza virus vaccine that is quadrivalent (ccIIV4) and derived from cell cultures that contains preservative and are antibiotic-free, while 90682 reports a new influenza vaccine that is quadrivalent (RIV4), hemagglutinin (HA) protein-only influenza vaccine product that is preservative and antibiotic-free, and derived from recombinant deoxyribonucleic acid (DNA).
Code 90750 describes intramuscular vaccination for shingles (recombinant, subunit, adjuvanted), and is effective Jan. 1, 2017.

INR Services

Due to the critical nature of thinning blood or reducing its clotting factor, patients on warfarin require constant oversight, along with international normalized ration (INR) testing. New code 93792 reports the education for the patient or caregiver for home INR monitoring; 93793 reports the provider’s management and oversight. Codes 99363 and 99364 are deleted.

Exercise Testing

The review of 94620 revealed the code has been used to report two different tests that involved different work. As a result, two new codes 94617 Exercise test for bronchospasm, including pre- and post-spirometry, electrocardiographic recording(s), and pulse oximetry and 94618 Pulmonary stress testing (eg, 6-minute walk test), including measurement of heart rate, oximetry, and oxygen titration, when performed are created to properly describe the services. Code 94620 is deleted and 94621 is revised.

Category III Codes

As always, changes are plentiful among the “emerging technology” Category III codes.
Code 0254T (endovascular repair of iliac artery bifurcation) is revised to include all selective and/or nonselective catheterization(s) required for device placement and all associated radiological S&I. As a result, 0255T is deleted.
Code 0488T is added to report diabetes prevention programs using a standardized diabetes prevention curriculum, either online or through electronic technology.
Three new codes describe the implantation, revision, replacement, or removal of the chest wall sensor(s) attached to a cranial nerve neurostimulator electrode array and pulse generator for the treatment of selected patients with obstructive sleep apnea:
+0466T reports the insertion of the chest wall respiratory sensor electrode.
0467T reports the revision or replacement of the chest wall respiratory sensor electrode.
0468T reports the removal of the chest wall respiratory sensor electrode.
Two new codes are created to report optical coherence tomography  for microstructural and morphological imaging of skin: 0470T reports the first lesion treated and 0471T reports each additional lesion treated.
New codes report the evaluation and interrogation of an intraocular retinal electrode array, which may be used to treat patients with severe retinitis pigmentosa, with bare light perception or no light perception. Code 0472T reports initial programming of the intraocular array, and 0473T reports the reprogramming of the intraocular array. Both include review and report.
Four new codes report fetal magnetocardiography — a non-invasive technique for studying the electrical activity of the fetal heart to diagnose and classify fetal cardiac arrhythmias.
0475T reports patient recording and storage, data scanning with signal extraction, technical analysis and result, and supervision, review, and interpretation of report.
0476T reports patient recording and data scanning, with raw electronic signal transfer of data and storage.
0477T reports signal extraction, technical analysis, and result.
0478T reports review and interpretation.
Two new codes report ablative treatment of burn and traumatic scars. Code 0479T reports the first 100 cm² in adults, or part thereof, or 1 percent of infants and children; 0480T reports the each additional 100 cm² in adults, or part thereof, or 1 percent of infants and children.
New codes report transcatheter mitral valve implantation (TMVI)/replacement with prosthetic valve placement. Code 0483T reports a percutaneous approach; 0484T reports a transthoracic exposure.
Also new are codes to report autologous adipose-derived regenerative cell therapy, which assists in the treatment of diagnoses or conditions such as sclerodactyly; progressive systemic sclerosis; calcinosis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia (CREST) syndrome; and systemic sclerosis induced by drug and chemical. Code 0489T reports the harvesting, isolation, and preparation of the cells, removal of non-viable cells, and determination of the concentration and dilution; and 0490T reports the injections of the autologous adipose-derived regenerative therapy in one or both hands.
Three new codes report ex-vivo assessment procedures of marginal donor lungs prior to transplantation. The procedure is performed to determine the viability of the transplantation, prior to the backbench work and transplantation. Code 0494T reports surgical preparation and cannulation, and 0495T reports the first two
hours of initiation and monitoring of the marginal (extended) cadaver donor lung(s) organ perfusion system. Code +0496T reports each additional hour of initiation and monitoring marginal (extended) cadaver donor lung(s) organ perfusion system.
New codes describe external, patient-activated, prescribed electrocardiographic rhythm-derived event recording without 24-hour attended monitoring. Code 0497T reports the in-office connection; and 0498T reports the review and interpretation of at least one patient-generated triggered event. Report once per 30-day period.
Four new codes report non-invasive estimated coronary fractional flow reserve (FFR). This technology provides a combined anatomic and physiologic assessment of coronary artery disease in a single noninvasive test that can help select patients for invasive angiography and revascularization or the best medical therapy. Code 0501T includes all components of the procedure including data preparation and transmission, analysis, generation of estimated FFR model, anatomical data review, and interpretation and report. Code 0502T reports data preparation and transmission; 0503T reports analysis of fluid dynamics and simulated maximal coronary hyperemia, and generation of estimated FFR model. Code 0504T describes the physician interpretation and report.

More to Come

This is only a summary of changes: Keep reading Healthcare Business Monthly in the coming months for more in-depth exploration of new and revised codes and how to use them.

Co-written by Raemarie Jimenez, CPC, CPB, CPMA, CPPM, CPC-I, CDEO, CANPC, CRHC and John Verhovshek, MA, CPC, is managing editor at AAPC and a member of the Hendersonville-Asheville, N.C., local chapter

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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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