General Surgery Coding Alert
New Fine Needle Aspiration, Laparoscopic Codes Top List of 2002 CPT Changes
Dozens of code descriptors have been revised. Although most of the changes are cosmetic (for example, changing the word "bowel" to "intestine"), some are important clarifications that may significantly alter how some general surgeons bill for services.
Fine Needle Aspiration
FNA has two new codes:
FNA does not involve an incision. Instead, a needle is placed into a breast or thyroid mass to remove a sample of cells for examination. FNA is distinguished from other needle biopsies by the thinness of the needle used (usually 18-25 gauge). A cytology report as opposed to a histology report required with other biopsies also must be included within the patient's medical record. Until the introduction of these codes, this service was coded using 88170 (fine needle aspiration; superficial tissue [e.g., thyroid, breast, prostate]) and 88171 ( deep tissue under radiologic guidance). General surgeons typically performed 88170 on breast and thyroid patients.
The introduction of 10021 and 10022 and the deletion of 88170 and 88171 is a positive development because it removes this service, which is frequently performed by general surgeons, from the pathology section of the CPT manual and puts it in the surgical section, says Jan Rasmussen, CPC, a general surgery coding and reimbursement specialist in Eau Claire, Wis.
"Transferring FNA to the surgery section should make it easier to find the correct code and eliminate much of the confusion associated with having it in the pathology/lab section while all the other biopsy codes were considered surgical," she says.
Deleted codes 88170 and 88171 were broken down into professional and technical components and caused confusion because physicians sometimes had to include modifier -26 (professional component) for aspirating a sample but did not perform the technical component of the service, for example, the cost of the needle and supplies for smear preparation. Typically, modifier -26 had been used when FNA was performed in a facility setting, whereas 88170 or 88171 was billed without a modifier if the surgeon performed the entire procedure and provided the supplies.
With the new codes in the surgery section, Rasmussen believes it is unlikely the Medicare fee schedule (due to be released in early November) will maintain the professional/technical split. This should simplify matters for surgeons, who will likely be able to bill 10021 or 10022 regardless of setting (although the RVUs may still vary depending on place of service).
New and Revised Colectomy and Enterectomy Codes
Significant additions and changes were made to the colectomy and enterectomy sections. Topping the list is the introduction of three new laparoscopic codes that parallel already existing open procedure codes.
The first code is 44203 (laparoscopy, surgical; each additional small intestine resection and anastomosis [list separately in addition to code for primary procedure]). An add-on code, it should only be used with 44202 (laparoscopy, surgical; enterectomy, resection of small intestine, single resection and anastomosis), which also was significantly revised. Previously 44202 stated: laparoscopy, surgical; intestinal resection, with anastomosis (intra or extracorporeal).
Code 44202 applies regardless of how the laparoscopic procedure is performed the entire resection may be performed laparoscopically or may also involve making a small incision to pull the affected section of small intestine out of the body so it can be resected. Therefore, the simplification of the code's descriptor should eliminate confusion about its usage, says Kathleen Mueller, RN, CPC, CCS-P, a general surgery coding and reimburse-ment specialist in Lenzburg, Ill.
The other new laparoscopic codes involve colectomy:
Until now, the procedures described by 44203, 44204 and 44205 were reported with laparoscopy code 44209 (unlisted laparoscopy procedure, intestine [except rectum]).
"These new codes are the laparoscopic equivalent of three existing open procedure codes," Mueller says. "Other than the method of performing the procedure, 44203 and 44121 (enterectomy, resection of small intestine; each additional resection and anastomosis [list separately in addition to code for primary procedure]) are virtually identical."
The same is true for 44204 and 44140 (colectomy, partial; with anastomosis), as well as 44205 and 44160 (colectomy, partial, with removal of terminal ileum and ileocolostomy).
Mueller says CPT 2002 includes a small yet significant revision for 44160 the inclusion of the word "partial" after colectomy (which brings 44160 in line with 44205).
"Other codes in this section, such as 44140 (colectomy, partial; with anastomosis) and 44141 ( with skin level cecostomy or colostomy), include the word 'partial,' but 44160 did not, so some practices assumed that a total colectomy had to be performed to bill this code, even though that was never the case," Mueller says. "By including the word 'partial,' CPT is making it clear that 44160 can be used for a partial colectomy."
Trigger-Point Injection Codes
The existing code (20550) has been revised, so trigger-point injections should no longer be reported with this. Instead, CPT 2002 introduces two new trigger-point codes, as well as two other related codes for tendon origin/ insertion and carpal tunnel injections:
Note: The procedures described by both 20526 and 20551 were previously reported using the old trigger-point injection code (20550).
Code 20550 has a new descriptor injection; tendon sheath, ligament, ganglion cyst. The change means it applies only to superficial injections into the soft tissue.
The new codes simplify coding but may lessen reimbursement, Mueller says. Until now, trigger-point injections in different muscle groups could be billed separately using modifier -59 (distinct procedural service). Some carriers paid for as many as eight injections in a given session. As of Jan. 1, 2002, however, even if eight injections are performed, only 20553 may be billed, because it includes "three or more muscle groups."
Until CMS releases the fee schedule, the number of RVUs assigned to 20552 and 20550 is unknown. Although it is likely that these procedures may reimburse at a higher rate than a single 20550 claim used to, Mueller doubts 20553 could match multiple (up to eight) 20550 claims.
On the positive side, she says that reimbursement, though reduced, will probably be easier to obtain because the new codes are more specific.
Disappointments in CPT 2002
The deletion of modifier -60 (altered surgical field), introduced in 2001, tops the list of disappointments for general surgeons. In 2001, general surgeons welcomed modifier -60 and hoped it would make it easier to obtain additional reimbursement for procedures made more difficult by an altered surgical field (due to prior surgery or adhesions, for example).
However, a few weeks after the modifier was introduced, CMS announced that Medicare carriers would not recognize it, and instructed providers to continue using modifier -22 (unusual procedural services).
The deletion of modifier -60 has also resulted in another revision of modifier -22. CPT 2001 amended modifier -22, stating that "this modifier is not to be used to report procedure(s) complicated by adhesion formation, scarring, and/or alteration of normal landmarks due to late effects of prior surgery, irradiation, infection, very low weight ... or trauma (see modifier -60 as appropriate)." Although, at the time of writing, the revision to modifier -22 was not available, it may be assumed that these instructions are no longer valid. With modifier -60 deleted, modifier -22 should be used to report complicated procedures regardless of the reason for difficulty.
Also, many general surgeons wanted a laparoscopic inguinal and/or incisional hernia repair code to be introduced in 2002. This did not occur.
Other New and Revised Codes
Anal/Rectal
Code 46020 (placement of seton). CPT now includes a code that describes the removal of an anal seton (46030). Until now, the placement of the seton, a kind of stent that facilitates drainage and prevents abscess formation in patients with perianal lesions, such as fistula in ano, was not described by a CPT code.
Code 91123 (pulsed irrigation of fecal impaction). Impaction can be understood as extreme constipation, i.e., the inability to pass feces. It is often accompanied by pain and anorexia, and may require hospitalization. Traditional treatments include digital manipulation, enema instillation or spinal anesthesia. Pulsed irrigation, which was intro-duced as a method to evaluate the colon for colonoscopy, uses water jets, or pulses, to disrupt the impaction.
Because pulsed irrigation has been used with colonoscopies, carriers are likely to watch for abuse of this code, Mueller says. She adds that when CMS introduces the 2002 fee schedule, surgical practices should check if RVUs have been assigned to the code.
Liver Tumor Ablation
Some liver tumors cannot be excised, and in some cases the tumors are destroyed by radiofrequency or cryosurgery ablation. Although these procedures are typically performed by hepatic or biliary surgeons, general surgeons may also perform them. Now, an unlisted-procedure code (47379, unlisted laparoscopic procedure, liver; or 47399, unlisted procedure, liver) must be used to describe these procedures. But CPT 2002 introduces the following:
Note: No code was introduced for percutaneous cryosurgical ablation.
Bone Marrow Biopsy and Aspiration
Two codes have been introduced to report bone marrow aspiration and biopsy:
These replace two current pathology codes 85095 and 85102 that are deleted in CPT 2002.
Vascular Procedures
The following have been added to describe vascular procedures:
As a result of the introduction of 36820, the descriptor for 36819 ( by upper arm basilic vein transposition) has been revised to include the location, i.e., upper arm. Another significant revision involves 36005 (injection procedure for extremity venography [including introduction of needle or intracatheter]). By replacing "contrast" with "extremity," this code has effectively been taken away from general surgeons, who are unlikely to perform venography on extremities, Mueller says.
Pediatric Procedures
The following describe pediatric surgical procedures:
Two have been revised:
Category III CPT Codes
The AMA has established a new category of CPT codes category III tracking codes for emerging medical technologies. The codes are alphanumeric, consisting of four numbers followed by a letter, for example, 0001T. Many of these were introduced in 2001, but the 2002 CPT manual includes several new category III codes that relate to general surgery:
According to the AMA, the purpose of this category is "to facilitate data collection on and assessment of new services and procedures ... As such, the Category III codes may not conform to the usual CPT requirements that:
The AMA says these codes will not be referred to the Relative Value Update Committee because no RVUs are expected to be assigned. Individual Medicare carriers may opt to cover some of these services, according to a Sept. 14 CMS transmittal (AB-01-127). Providers should check the CMS national physician fee schedule for the status indicators for each code.
Typically, however, these codes will be used for reporting only, instead of an unlisted-procedure code, Rasmussen says. He adds that category III codes are expected to replace those in the HCPCS book by 2003.
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