Get to Know These Key 2012 CPT® Changes Torrey Kim, CPC, CGSC Nov. 22, 2011

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These Key Changes Can Help You Avoid Denial Moments Like This

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Agenda The Key E/M Changes for 2012 that you might have

missed

How to report integumentary services with the new

CPT® codes for skin substitutes

Reporting pacemaker replacements in 2012

Can’t miss pathology and radiology Changes

Adjustments in sight for the Medicare Annual Wellness Visit and ICD-10

Beyond 2012: What to expect in the coming years

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“Other Qualified Healthcare Professional” CPT® now defines this term, as follows: "A ‘physician or other qualified health care professional’ is an

individual who by education, training, licensure/regulation, and facility privileging (when applicable) who performs a professional service within his/her scope of practice and independently reports a professional service. These professionals are distinct from ‘clinical staff.’ A clinical staff member is a person who works under the supervision of a physician or other qualified health care professional and who is allowed by law, regulation and facility policy to perform or assist in the performance of a specified professional service. Other policies may also affect who may report specified services."

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“Other Qualified Healthcare Professional” What this means to you:

RNs and LPNs are not included in the definition

Those professionals therefore are precluded, according to CPT® rules, from reporting certain procedures such as immunization administration codes 90460-90461, neuropsychological testing code 96120, cognitive testing code 96125, and prolonged E/M codes 99358-99359, among others

State and local laws may specifically dictate who can perform each type of service, so check that as well.

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E/M Changes: New Patients CPT® 2012: “A new patient is one who has not received any professional services

from the physician or another physician of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.” (Changes underlined)

Example: A cardiology practice employs a general cardiologist and an electrophysiologist (EP), and both physicians are classified as these separate specialties with their payers. The cardiologist refers a patient to the EP for consideration of an implantable cardiodefibrillator. In this situation, the visit with the EP should qualify as a new patient visit, assuming the payer accepts these CPT® rules.

The specialties in the example above are not the “exact” same, so that’s why the new patient designation applies, according to Peter A. Hollmann, MD, chair of the CPT® Editorial Panel, during the CPT® 2012 Annual Symposium in Chicago on Nov. 16.

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E/M: Observation Coding CPT® 2012 adds typical time guidelines to the initial

observation codes (99218-99220), as follows:

99218 -- …Physicians typically spend 30 minutes at the bedside and on the patient’s hospital floor or unit

99219 -- …Physicians typically spend 50 minutes at the bedside and on the patient’s hospital floor or unit

99220 -- …Physicians typically spend 70 minutes at the bedside and on the patient’s hospital floor or unit

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E/M Coding: Observation Care What this means to you: Because

typical times are now associated with these codes, it should open the door to use time as a factor in coding the visit. In addition, they “become base codes for prolonged service codes,” Dr. Hollmann noted.

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E/M Coding: Prolonged Services CPT® has changed the definitions of 99354-99357 to

remove the phrase “face-to-face” because unit/floor time is used in non-outpatient settings.

The term “other qualified healthcare professional” has been added to the descriptor for these prolonged service codes

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Integumentary Changes Skin closures (12001-13160): CPT® previously advised the use of

modifier 51 (Multiple procedures) when reporting different wound repair classifications together - the guidelines were changed for 2012, said Albert E. Bothe, Jr., MD, during CPT® 2012 Annual Symposium on Nov. 17.

"The guidelines were clarified for repair, changing the modifier 51 that had been there to the distinct procedural service modifier, 59," he said.

In black and white: The 2012 CPT® manual reads, "When more than one classification of wounds is repaired, list the more complicated as the primary procedure and the less complicated as the secondary procedure, using modifier 59."

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Integumentary Changes What’s ‘complicated?’ Because CPT® offers simple,

intermediate, and complex repairs, you’d consider the "simple" repair the least complicated, and the "complex" repair the most complicated. Therefore, if a simple repair and an intermediate repair are performed together, you’ll report the intermediate repair first, followed by the simple repair (with modifier 59 appended).

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Integumentary Changes Debridement is considered “separate” by CPT®

standards “only when gross contamination requires a prolonged cleansing, when appreciable amounts of devitalized or contaminated tissue are removed, or when debridement is carried out separately without immediate primary closure," Dr. Bothe said.

Tip: Your documentation should fully describe the surgeon’s work cleansing the contamination and removing the devitalized tissue before you separately bill your insurer for debridement.

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Integumentary Changes Complete overhaul of skin substitute codes (15271-

15278) with deletions, revisions, and additions.

“For wounds that are smaller than 100 square centimeters, you’ll follow one code structure--if your wound is 100 square centimeters or greater, you’ll follow a separate code structure," said Christopher K. Senkowski, MD, at the Nov. 17 "CPT® Changes: General Surgery" seminar on Nov. 17.

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Skin Substitutes: Small wounds: Under the new coding rules, a skin substitution

graft performed for a wound surface area between 25 and 100 sq. cm would only have two possible primary coding options: 15271 (for trunk, arms, and legs) or 15275 (for face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits). Each of these codes represents the first 25 square centimeters repaired.

For each additional 25 sq. centimeters repaired, you’ll use either the add-on code +15272 (for trunk, arms, and legs) or +15276 ((for face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits).

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Skin Substitutes Small wound example: A diabetic patient presents

with a 50-square centimeter ulcer on the base of her foot. The surgeon applies a skin substitute graft to the wound. In this situation, you’ll report one unit of 15275 (to represent the first 25 sq. cm) and one unit of +15276 (for the second 25 sq. cm repaired).

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Skin Substitutes Large wounds: When performing skin substitute

applications to wounds that are 100 square centimeters or larger, you’ll only have two primary coding options: 15277 (for the face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits) or 15273 (for trunk, arms, and legs).

To represent each additional 100 square centimeters, you’ll report a unit of the add-on code +15278 (for the face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits) or +15274 (for trunk, arms, and legs).

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Skin Substitutes Large wound example: A patient falls asleep

smoking a cigarette and suffers burns to 20 percent of her body. The surgeon applies 300 square centimeters of skin substitute to her arms and trunk. In this case, you’ll report one unit of 15273 (to represent the first 100 square cm), and two units of the add-on code +15274 to represent the remaining 200 square cm.

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Integumentary Coding Important: New add-on code +15777 (Implantation of

biologic implant [eg, acellular dermal matrix] for soft tissue reinforcement [eg, breast, trunk]) does not apply to mesh used in hernia procedures.

"New code +15777 was developed for areas where there’s a defect from a tumor resection, or where there’s a need for fascia support such as a breast situation--it’s not something you’re going to use in conjunction with a hernia repair," said Dr. Senkowski.

Instead, mesh implantation for hernia repairs should be reported with +49568, he said.

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Orthopedic Coding New arthrodesis codes:

22633 -- Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment, lumbar

+22634 -- ...each additional interspace and segment (List separately in addition to code for primary procedure)

• These codes were developed “to report lumbar arthrodesis utilizing a combined posterior or posterolateral technique with a posterior interbody technique including laminectomy and/or discectomy sufficient to prepare the interspace (other than for decompression) for each interspace and segment,” said R. Dale Blasier, MD, at the CPT® Symposium on Nov. 18.

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Orthopedic Coding CPT® 2012 revises 29581, which in 2012 will read,

"Application of multi-layer compression system; leg (below knee), including ankle and foot." In addition, CPT® will add the following codes after 29581:

29582 -- Application of multi-layer compression system; thigh and leg, including ankle and food, when performed

29583 -- ...upper arm and forearm

29584 -- ...upper arm, forearm, hand, and fingers

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Pulmonology CPT® deletes 32095 (Thoracotomy, limited, for biopsy

of lung or pleura), and it will be replaced with the following more specific codes :

32096 -- Thoracotomy, with diagnostic biopsy(ies) of lung infiltrate(s) (eg, wedge, incisional), unilateral

32097 -- Thoractomy, with diagnostic biopsy(ies) of lung nodule(s) or mass(es) (eg, wedge, incisional), unilateral

32098 -- Thoractomy, with biopsy(ies) of pleura

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Pulmonology CPT® 2012 changes the heading of its "Thoracoscopy" section to include the

term "VATS" (video-assisted thoracic surgery), and debuted three diagnostic thoracoscopy codes

32607--Thoracoscopy; with diagnostic biopsy(ies) of lung infiltrate(s) (eg, wedge, incisional), unilateral

32608--...with diagnostic biopsy(ies) of lung nodule(s) or mass(es) (eg, wedge, incisional), unilateral

32609--...with biopsy(ies) of pleura

"Diagnostic thoracoscopies (32607-32609) have zero-day globals," said Francis C. Nichols, III, MD, during his "CPT® Changes: Cardiothoracic Surgery" presentation on Nov. 17. "We actually have in a recommendation to change those to ten-day globals which would reflect the time the patient spends in the hospital which can be up to ten days, but that has not yet changed." Therefore, physicians can separately report E/M services that they provide to patients during the related hospital stay.

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Cardiology For a pacing cardioverter-defibrillator, 33249 changes

as follows:

2011: Insertion or repositioning of electrode lead(s) for single or dual chamber pacing cardioverter-defibrillator and insertion of pulse generator

2012: Insertion or replacement of permanent pacing cardioverter-defibrillator system with transvenous lead(s), single or dual chamber.

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Cardiology When you need to code electrode repair, you’ll choose between

these revised codes:

33218, Repair of single transvenous electrode, permanent pacemaker or pacing cardioverter-defibrillator

33220, Repair of 2 transvenous electrodes for permanent pacemaker or pacing cardioverter-defibrillator.

Helpful: The change solves confusion over how to code repair of a single electrode in a dual-chamber system. In 2011, the code definitions offer no obvious solution because 33218 refers to repair of one electrode in a single-chamber system and 33220 references repair of two electrodes in a dual-chamber system.

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Cardiology At the CPT® Symposium on Nov. 18, Kenneth Brin,

MD, PhD, encouraged coders to focus on the new catheterization code tables on pages 493-495 of CPT® 2012 to accurately code these services.

For instance, using the table to code a cath placement in coronary arteries for coronary angiography, including intraprocedural injections for coronary angiography, imaging supervision and interpretation, the chart leads you to report 93454 with add-on code 93567.

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Ob-Gyn Coding CPT® 2012 deletes 11975 (Insertion, implantable

contraceptive capsules) and 11977 (Removal with reinsertion, implantable contraceptive capsules).

You’ll now have to look to the existing code 11981 (Insertion, non-biodegradable drug delivery implant) when your ob-gyn inserts Implanon for contraception.

The code 11976 (Removal, implantable contraceptive capsules) remains a valid CPT® code, however, because some patients still have Norplant systems that an ob-gyn will need to remove.

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Ob-Gyn Coding Example: A patient comes in for removal of the

Norplant and has an Implanon rod inserted at the same encounter, CPT® instructions say to report 11976 and 11981. That means, your claim will look like this: 11976, 11981-51 (Multiple procedures). Your diagnosis code for this combination will be V25.13 (Encounter for removal and reinsertion of intrauterine contraceptive device).

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Pain Management/Neurology Coders who report paravertebral face joint nerve injections will find big

changes awaiting this year, with codes 64622-64627 wiped away from the new edition of CPT®. Instead, you’ll find the following revamped code set in their place:

64633 -- Destruction by neurolytic agent, paravertebral facet joint nerves with imaging guidance (Fluoroscopy or CT), cervical or thoracic, single facet joint

+64634 -- ...cervical or thoracic, each additional facet joint (List separately in addition to code for primary procedure)

64635 -- ...lumbar or sacral, single facet joint

+64636 -- …lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure)

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Pain Management/Neurology A parenthetical note following the new codes

indicates that imaging guidance (fluoroscopy, CT) "are inclusive components of 64633-64636," so you should not separately report image guidance, injection, or contrast with these codes. "If CT or fluoroscopic imaging is not used, report 64999, Unlisted procedure, nervous system)," CPT® notes.

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Pain Management/Neurology CPT® confirms that nerve block codes 64490-64495

now include trigger point injections as well as imaging guidance, according to CPT®.

If you do not use imaging, you’ll report a trigger point injection code (20552-20553) instead, said Marc L. Leib, MD, JD, at the CPT® Symposium on Nov. 17.

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Neurology If your physician ever performs electromyography (EMG) along with

nerve conduction studies, you now have three add-on codes to report those EMG tests, as follows:

+95885 -- Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary procedure)

+95886 -- ...complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary procedure)

+95887 -- Needle electromyography, non-extremity (cranial nerve supplied or axial) muscle(s) done with nerve conduction, amplitude and latency/velocity study (List separately in addition to code for primary procedure)

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Neurology Reason for ‘add-on’ status: Keep in mind that these new

codes should only be reported as add-on codes when nerve conduction studies (95900-95904) are also performed. If your physician performs an EMG but does not perform nerve conduction studies, then resort to the existing EMG-only codes (95860-95872).

Double add-ons may be okay: CPT® explains the usage of the new EMG codes in its "electromyography" introductory notes, where it states, "Report either 95885 or 95886 once per extremity. Codes 95885 and 95886 can be reported together up to a combined total of four units of service per patient when all four extremities are tested."

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Radiology CPT® 2012 introduces new code 74174 (Computed

tomographic angiography, abdomen and pelvis, with contrast material[s], including noncontrast images, if performed, and image postprocessing). This serves as a combination of codes 74175 (CTA abdomen) and 72191 (CTA pelvis) for practices that perform this combination study.

As before, if you perform only a CTA abdomen, you’ll report 74175; if you perform a CTA pelvis, look to 72191, and if you perform a CTA abdomen and pelvis, you’ll bill new code 74174.

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Radiology 78584-78598 will be completely deleted, and code 78580 revised to say

"Pulmonary perfusion imaging (eg, particulate).” In place of the deleted codes, you’ll find the following:

78579 -- Pulmonary ventilation imaging (eg, aerosol or gas)

78582 -- Pulmonary ventilation (eg, aerosol or gas) and perfusion imaging

78597 -- Quantitative differential pulmonary perfusion, including imaging when performed

78598 -- Quantitative differential pulmonary perfusion and ventilation (eg, aerosol or gas), including imaging when performed

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Radiology The difference: Perfusion essentially tells the physician if there

are any blood flow restrictions in the lungs. For perfusion, the provider injects protein particles tagged with a radioactive material that travel through the vascular system. The pulmonary circulatory system’s small arterioles (small diameter blood vessels) trap the relatively large particles. The provider takes a series of images to assess lung perfusion (blood flow). Radioactivity won’t be visible in the non-perfused areas, so the radiologist can spot where the blood flow problems are.

“If you’re doing a ‘V’ ventilation and ‘Q’ perfusion at the same time, you now use one code,” said Richard Duszak, Jr. MD,

during his Nov. 18 presentation at the CPT® Symposium.

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Radiology – Medicare Pay The 2012 Final Rule expands the existing multiple procedure

payment reduction policy to the professional interpretation of advance imaging services, further reducing those payments beyond 2011 levels.

The cuts: “When there are two or more radiologic services provided to the same patient in the same session on the same day, irrespective of the anatomic location, it will be full payment for the first service, and a 50% reduction to the technical component for the second service, and a 25% reduction in the professional component for the second service.” – Kenneth B. Simon, MD, MBA, senior medical officer with CMS, at the 2012

CPT® 2012 Annual Symposium on Nov. 16, 2011.

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Pathology Coding CPT® 2012 adds an entire Molecular Pathology code section to

the manual (81200-81408).

These procedures involve the analyses of nucleic acid to detect

gene variants, according to a presentation at the CPT® Symposium by Mark S. Synovec, MD and Jonathan Myles, MD on Nov. 17.

Medicare’s contractors are currently pricing these codes, CMS’s Marc Hartstein said at the Symposium on Nov. 16. Although CMS decided not to price new molecular pathology codes under the current Clinical Laboratory Fee Schedule or the Physician Fee Schedule, the agency does intend to establish payment for them in 2013, Hartstein said.

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Ophthalmology CPT® 2012 will delete 92070 (Fitting of contact lens for

treatment of disease, including supply of lens) and introduces two codes in its place, as follows:

92071 – Fitting of contact lens for treatment of ocular surface disease

92072 – Fitting of contact lens for management of keratoconus, initial fitting

You’ll report 99070 in addition to these codes to represent the actual supplies that the physician provides to the patient, said Michael X. Repka, MD, at the CPT® Symposium on Nov. 17.

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Audiology/Otolaryngology CPT® will introduce new code 92558 (Evoked otoacoustic

emissions, screening [Qualitative measurement of distortion product or transient evoked otoacoustic emissions], automated analysis) as a new code. The following revised codes will be listed after it:

92587 -- Distortion product evoked otoacoustic emissions; limited evaluation (to confirm the presence or absence of hearing disorder, 3-6 frequencies) or transient evoked otoacoustic emissions, with interpretation and report

92588 -- comprehensive diagnostic evaluation (quantitative analysis of outer hair cell function by cochlear mapping, minimum of 12 frequencies), with interpretation and report

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Audiology/Otolaryngology In addition, CPT® appears to be taking into account the

length of time it takes to evaluate a patient for a new hearing device, adding time guidelines to code 92605 and offering a new add-on code for additional time, as follows:

92605 -- Evaluation for prescription of non-speech-generating augmentative and alternative communication device; face-to-face with patient; first hour

+92618 --...each additional 30 minutes (List separately in addition to code for primary procedure

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Pediatrics You’ll find the following new codes for car seat testing:

94780 -- Car seat/bed testing for airway integrity, neonate, with continual nursing observation and continuous recording of pulse oximetry, heart rate and respiratory rate, with interpretation and report; 60 minutes

+94781 -- ...each additional full 30 minutes (List separately in addition to code for primary procedure)

These tests are typically required before babies at risk for oxygen desaturation or obstructive apnea, or those who are premature, are discharged home from NICU settings.

“When the infant is ready to go home from the hospital, these tests are performed to ensure that the child can safely travel home in the car seat,” said Scott Manaker, MD, PhD, at the CPT® Symposium on Nov. 17.

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Pediatrics Existing developmental testing codes 96110-96111 will see the following

changes:

96110 -- Developmental screening, with interpretation and report, per standardized instrument form

96111 -- Developmental testing, (includes assessment of motor, language, social, adaptive, and/or cognitive functioning by standardized developmental instruments), with interpretation and report

These changes are significant in that CPT® 2011 lists both codes as developmental "testing" codes, with 96110 referring to "limited" testing and 96111 describing "extended" tests. Now the descriptors more closely relate to how practices actually refer to these codes, since many doctors document "screening" when they perform the services described by 96110.

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Annual Wellness Visits CMS has acknowledged the need for a health risk

assessment (HRA) to go along with annual wellness visit codes G0438 (Annual wellness visit, including a personalized prevention plan of service, first visit) and G0439 (…subsequent visit).

CMS estimates that physician office staff time for helping beneficiaries complete an HRA should be 10 minutes for the first AWV and five minutes for subsequent AWVs, and because of that added time, CMS slightly increased the RVUs for these codes for 2012.

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Annual Wellness Visit The HRA is an evaluation tool that meets the minimum following requirements, CMS

indicates in its 2012 Physician Fee Schedule Final Rule: Collects self-reported information about the beneficiary, can be administered independently by the patient or administered by a health professional before or during the AWV, is tailored to the patient, and takes into account any communication needs, such as limited English proficiency or literacy issues, takes 20 minutes or less to complete, and addresses the following topics, at a minimum:

Demographic data, including age, gender, race, and ethnicity

Self-assessment of health status, frailty, and physical function

Psychosocial risks including depression/life satisfaction, stress, anger, loneliness/social isolation, pain, or fatigue

Behavioral risks including tobacco use, physical activity, nutrition and oral health, alcohol consumption, sexual practices, motor vehicle safety (seat belt use), and home safety

Activities of daily living, including dressing, feeding, toileting, grooming, physical ambulation (including balance/risk of falls), and bathing

Instrumental activities of daily living, including shopping, food preparation, using the phone, housekeeping, laundry, transportation, responsibility for own medications, and ability to handle finances.

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Beyond 2012 For 2013, the CPT® Editorial Committee will continue

to monitor which code sections require revisions, but intends to offer special focus to psychiatry services, molecular pathology, cardiology and moderate sedation in 2013, the CPT® Symposium presenters said.

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ICD-10 Oct. 1, 2013 will mark the beginning of CMS’s requirement that

all practices switch to the ICD-10 system. However, the AMA has taken a stand against the new diagnosis coding system, which led the AMA’s House of Delegates to formally request a repeal to ICD-10 during its Nov. 15 meeting.

This does not mean that ICD-10 won’t go into effect, but it does mean that the AMA is trying to find a workaround to avoid the resources that each practice will have to put into the ICD-10 migration. A formal ICD-10 repeal could only take place following governmental intervention.

During a Nov. 17 "ICD-10 Implementation" call, CMS’s Denise Buenning said “There is no truth to the rumor, there is no pushback--the date for ICD-10 remains Oct. 1, 2013.”

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Beyond 2013 At the CPT® Symposium, CMS reps also illuminated

one major change that could be coming up the pike for practices in the future.

In 2015, CMS will begin to phase in the use of a value-based modifier that gives a "differential payment to a physician or group of physicians based on the quality of care compared to cost," Dr. Simon said. In other words, physicians whose patients have better outcomes will get paid more. The initial payments, which will be issued under the 2015 fee schedule, will be based on performance in 2013.

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Thank you! Please visit our Web site at www.supercoder.com for

additional CPT 2012 resources.

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