Practice Management Alert

Radiology and thoracentesis code updates also top the CPT® 2013 changes you'll want to know.

Starting Jan. 1, 2013 you'll have a whole slew of code additions, revisions, and deletions to incorporate into your billing. If you aren't taking note of the changes, you'll face countless denials to ring in the new year.

We've taken a look through all the code codes and have compiled must-have details on some of the changes to help you start your preparation now and get a jump-start on the transition.

Look Beyond Radio Communication Before Billing Critical Care

If you bill for a pediatrician or a pediatric ED, you might want to make note of this language change as well for pediatric critical care transport.

The non-face-to-face direction of emergency care to a patient's transporting staff by a physician located in a hospital or other facility by two-way communication is not considered direct face-to-face care and should not be reported with 99466 and 99467.

• 99466 -- Critical care face-to-face services delivered by a physician, face-to-face, during an Interfacility transport of critically ill or critically injured pediatric patient, 24 months of age or younger; first 30-74 minutes of hands-on care during transport
• 99467 -- ... each additional 30 minutes (List separately in addition to primary service)

Physician directed non face-to-face emergency care through outside voice communication to transporting staff should be reported using 99288 (Physician or other qualified health care professional direction of emergency medical systems [EMS] emergency care, advanced life support) or 99485and 99486 based upon age and clinical condition of the patient.

Map in New Codes for Coordination, Transfer of Care

The E/M section contains new E/M codes for coordination of complex care (99487-99489) and transitional care management services (99495-99496). These codes are the result of a special CPT® Workgroup tasked with finding a way to capture the additional work associated with these tasks above and beyond what would typically be covered in the post service work of another E/M code such as an inpatient hospital visit. These codes were expedited through the CPT® process to be ready for 2013 usage, says Michael A. Granovsky, MD, FACEP, CPC, President of LogixHealth, a medical coding and billing company in Bedford, MA.

Complex Chronic Coordination of Care Services

The new complex coordination of care codes describe patient management and support services to an individual that require clinical staff to implement a care plan involving multiple disciplines, which are directed by the physician or other qualified healthcare professional. The reporting provider oversees the management and or coordination of needed services for all medical conditions, psychosocial needs and activities of daily living. The typical patient for these coordination codes would have multiple chronic conditions expected to last for the foreseeable future and that place the patient at significant risk of death or decline. Examples would be patients suffering from multiple co-morbities such as dementia, chronic obstructive pulmonary disease or diabetes that complicate their care, says Granovsky.

Codes 99487-99489 are reported only once per calendar month and include all non-face-to-face complex chronic are coordination services and none or one face-to-face office or other outpatient visit. Only one physician or other qualified health care professional a can report the code for a particular patient during the calendar month, he adds.

Code 99487 is reported when there is no face-to-face visit with the physician during the month and at least 31 minutes of clinical staff time in coordination of care activities. The clinical staff time clock can not include any time spent on the date the physician is reporting another E/M service.

Code 99488 is reported when there is a face-to-face visit with the physician or other qualified health care professional during the month and there is at least 31 minutes of clinical staff time in coordination of care services.

Not for ED providers? Although emergency physicians do provide some oversight of complex chronic coordination of care and CPT® does not specify which medical specialties are allowed to report these codes; it seems unlikely the emergency physician will meet the qualifications as outlined in the preamble for this section. The requirement for supervising the staff that performs the care coordination functions would not be typical outside the ED setting, says Granovsky.

Look to These Major Chest Drainage Procedure Code Revisions

In CPT® 2013, we see a reorganization of the codes used to describe chest drainage procedures with some prior codes being deleted and replaced with new codes.

Codes 32420, 32421, and 32422 have been deleted:

• 32420 -- Pneumocentesis, puncture of lung for aspiration
• 32421 -- Thoracentesis, puncture of pleural cavity for aspiration, initial or subsequent
• 32422 -- Thoracentesis, with insertion of tube, includes water seal (e.g., for pneumothorax), when performed (separate procedure)

To report those services you should now use one of the four new codes thoracentesis codes

• 32554 -- Thoracentesis, needle or catheter, aspiration of the pleural space; without imaging guidance
• 32555 -- ...with imaging guidance
• 32556 -- Pleural drainage, percutaneous, with insertion of indwelling catheter; without imaging guidance
• 32557 -- ...with imaging guidance.

Coding example: Consider this case: A 72-year-old male with a known history of lung cancer presents with increasing dyspnea. Chest x-ray reveals a large left pleural effusion. The attending physician inserts a needle and drains the pleural effusion and the patient becomes more comfortable. No mention is made of imaging guidance. While in 2012 this procedure would have been reported with 32421, the correct coding as of date of service Jan. 1 2013 will be 32554.

Add New Appendix G Assignments For ED Procedures

Code 32551, tube thoracotomy has new descriptor language.

• 32551 -- Tube thoracostomy, includes includes water seal connection to drainage system (e.g., for abscess, hemothorax, empyema water seal), when performed, open (separate procedure)

Remember: The target symbol  means it is an Appendix G code with moderate sedation bundled into the value and not separately reportable unless specific requirements are met. Moderate sedation may be reported in addition to an Appendix G code if the procedure is performed in a facility setting and a second provider is involved. CPT® states, "In the unusual event when a second physician other than the health care professional performing the diagnostic or therapeutic services provides moderate sedation in the facility setting (e.g., hospital, outpatient hospital/ambulatory surgery center, skilled nursing facility) for the procedures listed in Appendix G, the second physician can report 99148-99150." CPT® codes 36010 and 36140 now appear in Appendix G.

Discern Other Qualified Health Care Professional Language Venipuncture Codes

Venipuncture codes now include the "other qualified health care provider" language.

• 36400 -- Venipuncture, younger than age 3 years, necessitating physician'sthe skill of a physician or other qualified health care professional, not to be used for routine venipuncture; femoral or jugular vein
• 36410 -- Venipuncture, age 3 years or older, necessitating physician's the skill of a physician or other qualified health care professional (separate procedure), for diagnostic or therapeutic purposes (not to be used for routine venipuncture)

Watch For Imaging Guidance Not Included In The Code Descriptor

In the introduction to the Radiology Section of CPT®, we see new wording for Supervision and Interpretation direction. It warns coders to check the code descriptors carefully to see if the surgical procedure under consideration contains imaging guidance or not. If it does, the imaging can't be separately reported. However, if there is no mention of imaging guidance in a code from the Medicine section of CPT®, radiological supervision and interpretation may be reported for the portion of the service that requires imaging. Remember that both services require image documentation, and the radiological supervision, interpretation and report, says Granovsky.

Also, look for an increase in the number of views required for cervical spine x-rays.

• 72040 -- Radiologic examination, spine, cervical; 2 or 3 views or less
• 72050 -- ...minimum of 4 or 5 views
• 72052 -- ...complete, including oblique and flexion and /or extension studies 6 or more views

We see the "other qualified healthcare professional" language appearing in the radiology section as well as the E/M section. For example:

• 76000 -- Fluoroscopy (separate procedure), up to one hour physician or other qualified health care professional time, other than 71023 or 71034 (e.g., cardiac fluoroscopy)

Be Confident With Reporting Multiple 64612s

CPT® 2013 clarifies longstanding questions from coders and pain management specialists regarding 64612 usage. The code describes chemodenervation of muscles innervated by the facial nerve to treat conditions such as blepharospams (333.81, Other extrapyramidal disease and abnormal movement disorders; blepharospasm) or hemifacial spasm (351.0, Facial nerve disorders; Bell's palsy).

Opinions have varied regarding whether you can legitimately report 64612 multiple times if the physician performs chemodenervation on the facial nerve (cranial nerve VII) during the same encounter. The Medicare Physician Fee Schedule (MPFS) lists 64612 as a code that allows bilateral reporting, but the revised descriptor for 2013 puts the question to rest: 64612 (Chemodenervation of muscle[s]; muscle[s] innervated by facial nerve, unilateral [e.g., for blepharospasm, hemifacial spasm]).

Bottom line: You can report two units of 64612 if your physician administers chemodenervation to muscles innervated by the facial nerve on both sides of the patient's face. Indicate the situation on Medicare claims by appending modifier 50 (Bilateral procedure) to 64612. For non-Medicare payers, report 64612 on two separate lines with modifiers LT (Left side) and RT (Right side) appended. ››

"This helps immensely in clarifying the 'discrepancy' between Medicare's stance that 64612 could be reported as bilateral, and the AMA's stance that it would be reported only once for all injections," says Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, owner of MJH Consulting in Denver, Co.

Plus: In a similar revision, when CPT® 2013 goes into effect, 64614 will specifically represent chemodenervation to a single extremity. The new descriptor reads as follows: Chemodenervation of muscle(s); extremity and/or trunk muscle(s) (e.g., for dystonia, cerebral palsy, multiple sclerosis).

Add 64615 for Chronic Migraine Treatment

A new addition to your chemodenervation options in 2013 will be 64615 (Chemodenervation of muscle[s]; muscle[s] innervated by facial, trigeminal, cervical spinal and accessory nerves, bilateral [e.g., for chronic migraine]).

Currently: Until 64615 goes into effect, providers potentially report both 64612 and 64613 if they inject the muscles in the forehead area as well as muscles in the back of the head or upper neck area during the same encounter to treat chronic migraine. In those situations, a question arose regarding whether the provider could report both codes bilaterally, which could lead to potentially high reimbursement when compared to multiple Botulinum injections of an extremity. Introducing 64615 answers the question by offering a single code for the multiple-injection scenario.