How to Report Imaging Guidance with Small Joint Injection
During either aspiration or injection, imaging guidance may be employed to ensure accurate needle placement. In 2015, the AMA revised previous joint (or bursa) aspiration/injection codes to specify “without ultrasonic guidance,” while adding codes to describe the same procedures with ultrasonic (US) guidance (revised text is underlined).
20600 Arthrocentesis, aspiration and/or injection, small joint or bursa (eg, fingers, toes); without ultrasound guidance
20604 Arthrocentesis, aspiration and/or injection, small joint or bursa (eg, fingers, toes); with ultrasound guidance, with permanent recording and reporting
20605 Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); without ultrasound guidance
20606 Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); with ultrasound guidance, with permanent recording and reporting
20610 Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance
20611 Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting
If the provider performs joint aspiration/injection with the aid of US guidance, code application is straightforward: You will select 20604, 20606, or 20611 depending on the joint targeted.
Example: Using US guidance for precise needle placement, the provider injects bupivacaine into the knee joint for pain management. Because the knee is defined as a major joint, the correct code is 20611. You would not report the US guidance (e.g., 76942 Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation) separately because it is an inclusive component of the primary procedure.
If the provider aspirates/injects the joint/bursa without guidance of any kind, coding is equally straightforward: Select from among 20600, 20605, and 20610. For example, if the injection in the above example had occurred without any guidance, report 20610.
You May Separately Report Guidance Other Than US
Per CPT® instructions, you may separately report fluoroscopic, CT, or MRI imaging guidance for needle placement during joint/bursa aspiration/injection.
77002 Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device)
77012 Computed tomography guidance for needle placement (eg, biopsy, aspiration, injection, localization device), radiological supervision and interpretation
77021 Magnetic resonance guidance for needle placement (eg, for biopsy, needle aspiration, injection, or placement of localization device) radiological supervision and interpretation
In such a case, you would report the “without ultrasonic guidance” code for the aspiration/injection, as well as 77002, 77012, or 70021, as appropriate.
For example, if the provider injects bupivacaine into the knee joint for pain management using CT imaging guidance, the proper coding is 20610, 77012.
Manipulation Under Anesthesia Doesn’t Require Fixation
Question: May we report CPT® 23700 Manipulation under anesthesia, shoulder joint, including application of fixation apparatus (dislocation excluded) if no fixation device is used? Does “under anesthesia” mean general anesthesia?
Answer: Yes, and Yes. Per CPT Assistant:
May 2009; Volume 19: Issue 5
Question: Is it appropriate to report CPT code 23700 for manipulation of the shoulder joint under anesthesia if a fixation apparatus is not utilized?
Answer: Yes. Utilization of a fixation apparatus is not required in order to report CPT code 23700.
April 2005; Volume 15: Issue 4
Question: Is it appropriate to report CPT code 23700, Manipulation under anesthesia, shoulder joint, including application of fixation apparatus (dislocation excluded), when general anesthesia is not used?
AMA Comment: CPT code 23700 is intended to be reported for the manipulation only when performed under general anesthesia. The code descriptors, which include the phrase “requiring anesthesia” or “under anesthesia,” indicate that the work involved in that specific procedure requires the use of general anesthesia; therefore, it would not be appropriate to report code 23700 if general anesthesia is not provided.
Coding Chronic Care Management in 2017
Medicare allows separate payment under the Medicare Physician Fee Schedule (MPFS) for non-face-to-face care coordination services furnished on or after Jan. 1, 2015, to Medicare beneficiaries with multiple chronic conditions (e.g., diabetes and depression). With only one code describing chronic care management (CCM), coding is straightforward. This may change in 2017.
In the 2017 MPFS proposed rule, the Centers for Medicare & Medicaid Services (CMS) is proposing the following changes to CCM coding and related MPFS payment policies:
- New coding, including three codes to describe services furnished as part of the psychiatric collaborative care model (CoCM) and one to address behavioral health integration;
- Improved payment for cognition and functional assessment, and care planning for beneficiaries with cognitive impairment;
- Payment adjustments for routine visits furnished to beneficiaries whose care requires additional resources due to their mobility-related disabilities;
- Medicare payment for complex CCM services, and payment adjustments for the visit during which CCM services are initiated, to reflect resources associated with the assessment for, and development of, a new care plan;
- Medicare payment for non-face-to-face prolonged evaluation and management (E/M) services by the physician (or other billing practitioner) that are currently bundled, and a payment rate increase for face-to-face prolonged E/M services by the physician (or other billing practitioner) based on existing American Medical Association/Specialty Society Relative (Value) Update Committee recommendations.
Coding Chronic Care Management in 2017
CCM services are presently described by CPT® code 99490 Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements:
- Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient;
- Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline;
- Comprehensive care plan established, implemented, revised, or monitored
CPT® has approved a code to describe assessment and care planning for patients with cognitive impairment, but it will not be ready in time for valuation in 2017. Therefore, CMS is proposing to make payment for this service in 2017 using a temporary G code.
CPT® has also approved three codes that describe services furnished consistent with the psychiatric CoCM, but that they will also not be ready in time for valuation in 2017. To facilitate separate payment for these services furnished to Medicare beneficiaries during 2017, CMS is proposing to make payment through the use of three temporary G codes (GPPP1, GPPP2, and GPPP3), as well as a fourth temporary G code (GPPPX) to describe services furnished using a broader application of behavioral health integration in the primary care setting. CMS proposes to consider whether to adopt and establish values for the new CPT® codes under standard process, presumably for 2018.
Remember: These are only proposed changes. CMS is accepting public comment on the 2017 MPFS proposed rule until 5 p.m., September 6; and the final rule will be published in November.
Coding for CCM may be expanding, but the requirements remain the same. Within the patient record, documentation must show patient consent was given and that a comprehensive care plan was created and made available to the patient and to anyone within the practice or outside the practice, as appropriate, via CERHT.
Source: MLN Chronic Care Management
Hacker Offers 655,000 Stolen Health Records for Sale
The Centers for Medicare & Medicaid Services (CMS) recently learned of a potential security breach in which a hacker is offering for sale 655,000 records of orthopedic patients, according to an MLN Matters Special Edition Article (SE1616).
A hacker that goes by the name “thedarkoverlord” claims to be in possession of the healthcare records, according to HotHardware. The breach was first reported by DeepDotWeb, which has exclusive screenshots of some of the records provided by “thedarkoverlord” to prove the legitimacy of his dastardly deed.
Hacker Hits Midwest, Georgia
The stolen records span much of the country, with 48,000 coming from Farmington, Missouri (later revealed to be from Midwest Orthopedic Clinic); 210,000 from the Central/Midwest states; and 397,000 from Georgia, reports HotHardware. The records include Social Security and insurance policy numbers. The hacker is reportedly selling the records for Bitcoins, at a U.S. dollar equivalent of approximately $1 per name.
The hacker himself requested DeepDotWeb add a note to their online report, directed to the breached companies:
“Next time an adversary comes to you and offers you an opportunity to cover this up and make it go away for a small fee to prevent the leak, take the offer. There is a lot more to come.”
Of course, HIPAA-covered entities put a lot more on the line if they kowtow to such threats. “What we can hope for at this point is that the affected hospitals (and patients) get notified about the breach as quickly as possible,” writes HotHardware reporter Rob Williams.
Meanwhile, CMS reminds HIPAA-covered entities of their duty to notify the Secretary of the U.S. Department of Health and Human Services if a breach of unsecured protected health information belonging to them or a business associate is discovered. See 45 CFR Section 164.408 for breach notification guidelines.
Two days after this story broke, DeepDotWeb reported the “thedarkoverlord’s” claim of hacking into a U.S. healthcare insurance database containing no less than 9.3 million patient records.
The Hospitalist: New Hospitalist Billing Code Should Benefit Hospitalists, Patients
Raemarie Jimenez, CPC, vice president of certifications and member development at AAPC, discussed the future of specialty medical codes within the hospital setting in an article with The Hospitalist. Author Kelly April Tyrrell addresses the future of hospital specialty codes and how they are expected to help improve quality metrics in hospital settings. Jimenez states, “CMS wants the data it is using to be meaningful.”