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Today’s Presentation

CPT CodingPrinciples of CPT Coding and

CPT Code Changes for 2009

CPT is a Copyright of the American Medical Association


Course Faculty

R. Thomas (Tom) Loughrey, MBA, CCS-P

• Chairman, CEO & Co-Founder of Economedix• Certified Coding Specialist • BS Degree from Pennsylvania State University• Earned an MBA in Health & Hospital Administration

from the University of Florida• Former Hospital Administrator• Former Owner of a Medical Billing Company• Consultant to Physician Practices & Medical Societies• Member of Various Professional Organizations

Dealing with Medical Practice Management• Developed and Presented Thousands of Seminars

& Workshops Dealing with Practice Management


Today’s Course

CPT Coding & 2009 Updates

• Organization of the CPT Materials• Conventions, Guidelines & Modifiers• E&M Codes• Medical Examples• Special Surgery Section• 2009 Update Section• Summary


Organization of CPT™

• Introduction

• Sections & Guidelines

– Evaluation & Management Services

– Anesthesia

– Surgery

– Radiology

– Pathology & Laboratory

– Medicine

• Modifiers

• Additions and Deletions

• Clinical Examples

• Index– Instructions

– Modifying Terms– Code ranges– Conventions


CPT Sections

• Section Numbers– E&M 99201 to 99499– Anesthesia 00100 to 01999, 99100 to

99140– Surgery 10040 to 69990– Radiology 70010 to 79999– Pathology & Laboratory 80049 to 89399– Medicine 90281 to 99199


Instructions

• Select the name of the procedure that most accurately identifies the service performed

• List additional serv ices or procedures if performed

• Add any modify ing or extenuating circumstances to the listed service or procedure

• Adequately document the service in the patient medical record

• Any procedure or service may be used by any qualif ied physician


Format of the Terminology

The code number followed by a descriptor

25100 Arthrotomy, wrist joint; for biopsy

Shorthand convention (follows semi-colon)

25105 For synovectomy


Unlisted Procedure or Services and Special Reports

• Not every service performed by a physician is listed in CPT. Therefore, a specific code within each section is to be used to identify the service

15999 Unlisted procedure, excision pressure ulcer

• All unlisted services and unusual services should be accompanied by a special report


Code Symbols

Each year the book is updated and codes are added and deleted. Text may be revised as well.

New procedures are identified with a “”New descriptions of codes are identified with a “”

New and revised text other than descriptions are identified with “ ”


Code Symbols

Add-On codes are identified with a “+”Codes exempt from multiple procedure

modifiers (-51) are identified with a “”. They are not designated as “add-on” codes

These modifier -51 exempt codes have substantial revisions for 2008

codes include conscious sedation

Pending FDA approval


Using the Index

• Organized by main terms followed by up to three modifying terms

• There are four classes of main terms:– Procedure or service– Organ or anatomic site– Condition– Synonyms, eponyms and abbreviations


Classes of Main Terms

• Procedure or service– Angioplasty, catheterization or fetal testing

• Organ or anatomic site– Artery, Cerebrospinal fluid or knee joint

• Condition– Lesion, HIV or fracture

• Synonyms, eponyms and abbreviations– Anticoagulant & clotting inhibitors, Baker’s cyst,

EEG


The index is not a substitute for the code listings in the main sections. Always refer to the

main text to ensure the accuracy of the code selection and review relevant notes and descriptions


Guidelines

Each section of the main text is preceded with “Guidelines” to using the section


Guidelines

• Guidelines contain information on:1. Classifications 2. Definitions 3. Unlisted services 4. Special reports5. Use of clinical examples 6. Typical modifiers 7. Other important information


Modifiers – Appendix A

— 21 Prolonged E&M Services - deleted

— 22 Unusual Procedural Service

— 23 Unusual Anesthesia

— 24 Unrelated E&M service during post-op period

— 25 Significant, separately identifiable E&M service by same physician on same day as other service or procedure

— 26 Professional component

— 32 Mandated service

— 47 Anesthesia by surgeon



— 50 Bilateral procedure— 51 Multiple procedure— 52 Reduced services— 53 Discontinued procedure— 54 Surgical Care only— 55 Postoperative management only— 56 Preoperative management only— 57 Decision for surgery— 58 Staged procedure— 59 Distinct procedural service (CCI Edits)



— 62 Two surgeons— 63 Procedures on infant<4kg— 66 Surgical Team— 76 Repeat procedure by same physician— 77 Repeat procedure by another physician— 78 Return to operating room for related procedure

during post-op period— 79 Unrelated procedure or service by the same

physician during the post-op period— 80 Assistant at surgery— 81 Minimum assistant at surgery— 82 Assistant at surgery (no qualif ied resident

available)



— 90 Reference Lab

— 91 Repeat Clinical Diagnostic lab test

— 92 Lab Test alternative platform (eff. 1/1/08)

— 99 Multiple procedures


Evaluation & Management Codes

Definitions New and established patients Chief complaint Concurrent care Counseling


Levels of E&M Services

• Determined by key components:– History

• HPI, Past, family and Social History, ROS

– Examination• Based on presenting problem and clinical

judgment

– Medical Decision Making• Based on the number of diagnoses, amount

or complexity of data and risk associated with the presenting condition


Office or Other Outpatient Services 99201 - 99220

New Patients 99201 – 99205

Established Patients 99211 – 99215

Hospital Observation Services 99217-

99220


Hospital Inpatient Services 99221 - 99239

• Initial Hospital Care 99221 – 99223• Subsequent Hospital Care 99231 –

99233• Observation or Inpatient Care (same

day admit and discharge) 99234 –99236

• Hospital Discharge Services 99238 -99239


Consultations

• Advice or opinion requested by another physician

• May initiate diagnostic and therapeutic services

• Request must be documented in medical record

• Opinion or advice must be documented in medical record

• Must be communicated to referring physician in a written report


Two Categories of Consultations

1. Office

– New and established patients

2. Inpatient

Follow-up and Confirmatory consultation codes had been deleted in 2006


Emergency Department Services

• New and established patients99281 – 99285

• Physician directed emergency care99288

• Provided from an organized hospital based department designed for unscheduled patients presenting for immediate attention

• Must be available 24 hours a day


Critical Care Services

• Critical care is usually provided in a hospital critical care unit – but not always!

• Separate codes for adults (99291 and 99292), peds (99293 and 99294) and neonates (99295 and 99296)

• 99291 is for 30 to 74 minutes and 99292 is for each additional 30 minutes

Note: Revisions were made in 2005


Critical Care Services

• Critical care includes interpretation of cardiac output measures, chest x-rays, blood gases and stored data

• Also includes gastric intubation, temporary transcutaneous paceing, ventilator management and vascular access procedures

• Other services should be listed separately• If less than 30 minutes of time is spent on critical

care all serv ices should be listed separately• Time spent in critical care is bedside and unit time

only. Physician must be immediately available to patient


Immunizations & Vaccines

• Immunization Administration– For Vaccines and Toxoids 90465-90474– Listed in addition to material

• Vaccines and Toxoids– 90476 through 90748– 90749 - unlisted


Injections

Therapeutic, Prophylactic or Diagnostic 90782 for subcutaneous or

intramuscular 90783 Intra-arterial 90784 Intravenous 90788 IM injection of antibiotic


Surgery


Surgical Guidelines

• Surgical Procedures include:– The operation itself– Local infiltration– Metacarpal/Digital Block or topical

anesthesia– Normal, uncomplicated follow-up care


Surgical Guidelines

• Follow–Up care– Diagnostic procedures: recovery only– Therapeutic procedures: only that care that

is usual to the surgery (time based)• Complications should be reported by use of the

appropriate procedure.

• For example: treatment of a post-operative wound infection


Surgical Guidelines

• Add-On Codes– Indicated by a “+”–List can be found in Appendix E–Usually describe additional work

based on additional surgical sites–Example: multiple lesions


Surgical Guidelines

• Special Reports – pertinent information includes:–Complexity of symptoms–Final diagnosis–Pertinent physical findings–Diagnostic and therapeutic services–Concurrent care–Follow-up plan


Using The Surgical Sections

• Procedures are listed by physiologic systems

• Physiologic systems parallel surgical specializations – Example: Musculoskeletal system and

orthopedics or Cardiovascular system and cardio-thoracic surgery

• Procedure listings are found in the Index


Using The Surgical Subsections

Many sections have special notes and instructions

Extremely important to review for each specialty

A complete listing of all subsections is found in the Surgery Guidelines


Using The Surgical SubsectionsExamples• Repairs or closure – does not include adhesive

strips– Defined as Simple, Intermediate and Complex– Wound size and shape should be recorded– Multiple wounds size is added together from the

same anatomic area– The most complicated wounds are listed as primary

and less complicated as secondary– Debridement is separate only under gross

contamination– Involvement of nerves, blood vessels and tendons

is included unless they are themselves complex


Using The Surgical Subsections

Examples• Hernia Repairs

– Categorized by type: inguinal, femoral, inc isional, etc– Further categorized as init ial or recurrent– Addit ionally may be accounted for as reducible

versus strangulated– Use of mesh or other prostheses is not separately

reported except for inc isional hernia repair– The excision or repair of strangulated organs is

separately reported in addition to the repair– All codes for bilateral repairs have been deleted. Use –51 modifier for second procedure


CPT Changes for 2009

Appendix B lists the code changes for the current year

Pay attention to: New procedures are identified with a “”New descriptions of codes are identified with

a “”New and revised text other than descriptions

are identified with “…text…”“” is used to indicate conscious sedation


Modifier Changes for 2009

Prolonged E&M ServicesModifier 21 was redundant and has been

deleted for 2009. Existing add-on codes 99353 – 99357 identify prolonged face-to-face time with patients for surgical or clinical services, including evaluation and management services. Prolonged evaluation and management services should now be reported with add-on codes 99354 – 99357.


E&M Changes for 2009

Newborn and Pediatric CareExpansive changes to newborn/pediatric care

codes.Reorganization of newborn and pediatric care

services into a sequential segmentMany E/M codes have been deleted: 99289 99290;

99293 99300; 99431 99440.

Pediatric critical care age requirements were expanded to include codes for children up to 71 months of age (less than six years old).

New pediatric transport codes were also created.



Newborn and Pediatric Care99460 Initial hospital or birthing center care, per

day, for evaluation and management of normal newborn infant

A normal newborn infant is one who has experienced no antepartum, postpartum, or perinatal complications and may have been delivered by vaginal or cesarean birth. Report99460 when the newborn is examined in the hospital or birthing center for the first time.



Pediatric Critical Care Patient Transport99466 Critical care 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 less; first 30 74 minutes of handson care during transport

Critically ill patients under two years of age require monitoring and treatment that differs substantially from others because their physiologic responses to illness and treatments differ from adult responses.

Very young patients are also unable to communicate effectively their symptoms to the physician, making treatment more difficult.

This code reports the first 30 to 74 minutes of care from a physician while a child under two years of age is being transported from one facility to another.



Inpatient Neonatal and Pediatric Critical Care99469 Subsequent inpatient neonatal critical

care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or less

A critically ill neonate is being treated for complications that may be congenital, birth trauma, or the result of a maternal problem.

The most common causes of neonatal morbidity are low birth weight and prematurity.

Report 99469 when the neonate, 28 days or younger



Inpatient Neonatal and Pediatric Critical Care99477 Initial hospital care, per day, for the evaluation and

management of the neonate, 28 days of age or less, who requires intensive observation, frequent observations, and other intensive care services

Neonates require specialized monitoring and treatment because their physiologic responses to illness and treatments differ from adult responses. Neonates are also unable to communicate their symptoms.

The physician may be required to extensively observe the hospitalized neonate in order to assess health and determine treatment.

Code 99477 reports the first day of hospital evaluation and management of a patient less than 29 days old who requires extensive observation.


Anesthesia Changes for 2009

00211 Anesthesia for intracranial procedures; craniotomy or craniectomy for evacuation of hematoma

This new code will allow more precise reporting of anesthesia for patients with emergent conditions brought about by head trauma and hematoma.

Typically, these patients have worsening neurological symptoms, as well as systemic complications associated with head trauma (such as dysrhythmia and pulmonary edema).

Previously, anesthesia for evacuation of intracranial hematoma would have been reported with 00210 or 00212.


Anesthesia Changes for 2009

00567 Anesthesia for direct coronary artery bypass grafting; with pump oxygenatorA pump oxygenator is a device that substitutes the actions

of the heart and lungs—both pumping the blood to circulate it through the body, and oxygenating the blood before it is pumped. It is employed during open heart surgery. This function is also known as cardiopulmonary bypass.

Anesthesia codes previously have not differentiated between procedures requiring a pump oxygenator and those not requiring a pump oxygenator.

Code 00567 reports anesthesia for a coronary bypass procedure.


Integumentary Changes for 2009

+11001 Debridement of extensive eczematous or infected skin; each additional 10% of the body surface, or part thereof (List separately in addition to code for primary procedure)Coders have been mistakenly applying modifier 52 to code

11001 when less than 10 percent of the body service was debrided.

The intent of this code is to report debridement in addition to the initial 10 percent reported in the parent code, in increments of up to 10 percent additional body surface.

For example, if 36 percent of the body were debrided, the coder would report 11000 once for the first 10 percent and 11001x3—once each for the second and third 10 percent, and again for the extra 6 percent.


Integumentary Changes for 2009

+11201 Removal of skin tags, multiple fibrocutaneous tags, any area; each additional 10 lesions, or part thereof (List separately in addition to code for primary procedure)Coders have been mistakenly applying modifier 52 to code

11201 when less than 10 skin tags (or other lesions) were removed.

The intent of this code is to report skin tags in addition to the 15 reported in the parent code, in increments of up to 10 skin tags.

For example, i f 28 skin tags were excised, the coder would report 11200 once for the first 15 skin tags and 11201x2—once to report an additional 10 skin tags, and once to report an additional 3 skin tags (15+10+3=28).


Breast Code Changes for 2009

19296 Placement of radiotherapy afterloadingexpandable catheter (single or multichannel) into the breast for interstitial radioelement application following partial mastectomy, includes imaging guidance; on date separate from partial mastectomy

This revision clarifies the difference between 19296 and 19298. The difference between the two types of systems is that 19296 represents a single insertion site into the cavity created by the lumpectomy, while 19298 represents multiple insertion sites around the site of the malignancy. Report 19296 for cavity conforming brachytherapy catheters like SAVI, which uses an expandable bundle of catheters inserted through a single incision and expanded to resemble a bird cage, or MammoSite, which consists of a catheter surrounded by a balloon that fills the cavity. Report 19298 for multiplanar brachytherapy using multiple thin catheters inserted individually in a formation like a clothesline.


Musculoskeletal Changes for 2009

22856 Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes oestophytectomy for nerve root or spinal cord decompression and microdissection), single interspace, cervical

This code reports disc arthroscopy on the cervical spine from ananterior approach. Some minor cleanup in the language of surrounding codes was performed to create consistency in the code set.

Cervical disc arthroscopies from an anterior approach and using microscopy are preformed to treat cervical radiculopathy, degeneration and myelopathy. The disc tissue is excised and nerves are decompressed under fluoroscopic guidance.

This service previously was reported with Category III code 0090T, deleted for 2009.



27027 Decompression fasciotomy(ies), pelvic (buttock) compartment(s) (eg, gluteus mediusminimus, gluteus maximus, iliopsoas, and/or tensor fascia lata muscle), unilateralCompartment syndrome occurs when pressure builds within a

single muscle compartment, within a wall of fascia. The pressure can come from a swelling injury or from hematoma. Untreated, compartment syndrome in the buttock can lead to muscle necrosis, renal failure, or sepsis.

Decompression consists of opening the fascia to relieve the pressure. In 27057, debridement is required. This is a unilateral procedure.

Previously, this procedure would have been reported with 27025 for the decompression and a code from 11040 11043 series for the debridement.



27215 Open treatment of iliac spine(s), turberosityavulsion, or iliac wing fracture(s), unilateral, for pelvic bone fracture patterns that do not disrupt the pelvic ring, includes internal fixation, when performedFractures within the pelvic ring are among the most serious

fractures that can occur, typically due to blood loss, infection,and thrombosis. Most pelvic fractures are the result ofsignificant blunt impact, as seen in an automobile accident.

There has been confusion as to whether fractures of the pelvisare unilateral. The change in language in 27215 is intended to clarify how to report services associated with a fracture of the pelvic ring. This code reports pelvic bone fractures that do not disrupt the pelvic ring.



27396 Transplant or transfer (with muscle redirection or rerouting), thigh (eg, extensor to flexor); single tendon

The description of 27396 has been expanded to report either a transfer or transplant of a single tendon of the thigh for any reason.

Code 27397, an indented code for multiple tendons, changes as well, since the modification to the 27396 code description occurs before the semi-colon.


Cardiovascular Changes for 2009

35535 Bypass graft, with vein; hepatorenalNew code 35535 reports creation of bypass graft for

revascularization of the right kidney and lower extremity.

This procedure is performed on patients with a problematic aorta or who require right renal revascularization. To preserve the liver and hepatic artery flow, this procedure may be performed as an interposition saphenous vein grafted side to side at the common hepatic artery distal to its gastroduodenal origin and end to end at the right renal artery.

This code includes vein harvesting.



35570 Bypass graft, with vein; tibial-tibial, peroneal-tibial, or tibial/peroneal trunk-tibial

New code 35570 reports a tibial bypass during which all three tibial calf arteries are occluded.

This procedure is performed to treat ischemia in the lower extremity and includes vein harvesting.



35632 Bypass graft, with other than vein; ilio-celiac

Circulatory problems caused by plaque deposits in the vessels may lead to complications in the organs those vessels feed.

This code reports revascularization ilio-celiac bypass graft using synthetic conduit, including those made of polytetrafluoroethylene.


Gastrointestinal Changes for 2009

41512 Tongue base suspension, permanent suture techniqueThere are several types of s leep apnea, a disorder

in which breathing is disrupted during sleep. In obstructive s leep apnea, the volume and construction of the mouth and throat physically prevent adequate oxygen intake when the patient is supine.

A suture is taken from the floor of the mouth through the tongue, and is affixed to a screw in the mandible. The procedure is performed on a patient who has been sedated under general surgery. This procedure would previously have been reported with an unlisted code.



41530 Submucosal ablation of the tongue base, radiofrequency, one or more sites, per session

This code reports services that treat obstructive sleep apnea. Topical blocks are employed and radiofrequency energy is delivered to submucosaltissues to reduce tissue mass.

This radioablation technique was previously reported with Category III code 0088T.



+43273 Endoscopic cannulation of papilla with direct visualization of common bile duct(s) and/or pancreatic duct(s) (List separately in addition to code(s) for primary procedure)This add on code is reported with endoscopic retrograde

cholangiopancreatography (ERCP) to identify a new technology for exploration of the common bile and pancreatic ducts.

A smaller scope is threaded through the endoscope and the papilla is cannulated. The small scope moves through the biliary or pancreatic ducts, thereby providing direct visualization.

Previously, CPT® did not contain a code to describe this procedure.



43279 Laparoscopy, surgical, esophagomyotomy (Heller type), with fundoplasty, when performed

This procedure is performed to improve esophageal motility in case of achalasia, which is frequently caused by defects in the autonomic esophageal nerve response.

Previously no specific code was available to report this approach.



46930 Destruction of internal hemorrhoid(s) by thermal energy (eg, infrared coagulation, cautery, radiofrequency)The treatment of hemorrhoids has evolved

significantly in recent years, with thermal techniques moving to the forefront because these techniques provide improved outcomes.

New code 46930 reports thermal destruction of hemorrhoids and replaces three deleted codes, 46934, 46935 and 46936, which report “any method” destruction techniques.

The new code captures all thermal destruction—coagulation, cautery, or radioablation.



+49568 Implantation of mesh or other prosthesis for open incisional or ventral hernia repair or mesh for closure of debridement for necrotizing soft tissue infection (List separately in addition to code for incisional or ventral hernia repair)

• Laparoscopy is an increasingly popular approach for abdominal surgeries. Studies have found that there are fewer recurrences following laparoscopic repairs. The procedures are less invasive, and patients recover from laparoscopic surgery quicker than from traditional open surgeries.

• The word “open” was added to differentiate 49568 from the new laparoscopic codes.



49652 Laparoscopy, surgical, repair, ventral, umbilical, spigelian or epigastric hernia (includes mesh insertion when performed); reducible

New code 49652 reports the laparoscopic repair of a reducible ventral, umbilical, spigelian or epigastrichernia, with or without the use of mesh.

The word “open” was added to differentiate 49568 from the new laparoscopic codes.


Genitourinary Changes for 2009

55706 Biopsies, prostate, needle, transperineal, stereotactic template guided saturation sampling, including imaging guidanceStereotactic template guidance can be used to perform

systemic sampling of the prostate in a transperinealapproach. Saturation sampling is reported with new code 55706, and is used to assess the status of disease in order to manage its treatment, rather than being used as a diagnostic biopsy.

This services was previously reported with Category III code 0137T, deleted for 2009. Other changes to prostate coding for 2009 include the deletion of two codes, 52606 now reported with 52214, and 52853, now considered obsolete.

Previously this procedure was reported with 0137T, deleted for 2009.


Genitourinary Changes for 2009

57400 Dilation of vagina under anesthesia (other than local)

Confusion regarding the word “anesthesia” is eliminated with a change to codes 57400, 57410, and 57415.

The phrase “other than local” is added to clarify that each of these procedures are performed under general anesthesia or conscious sedation, either of which carries greater risk for the patient and more work for the physic ian.


Neurology Changes for 2009

61798 Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 complex cranial lesion

In cranial stereotactic radiosurgery, high dose ionizing radiation is administered in a single fraction to a well defined tumor or vascular formation within the brain, cerebral meninges, or skull base. Its advantages in cranial surgery are twofold: no incision is required and the toxic radiation is precisely delivered only to the defect using three dimensional computer-aided planning and immobilizing skeletal fixation of the head.

Radiosurgery codes are now selected according to lesion size. Code 61798 reports the treatment of one cranial lesion of a size equal to or greater than 3.5 cm.



62267 Percutaneous aspiration within the nucleus pulposus, intervertebral disc, or paravertebral tissue for diagnostic purposes

Aspiration of materials within the intervertebral disc can be useful in diagnosing discitis and its source of infection. There has been no code that captures the physician work and aftercare involved when the spinal disc is aspirated for diagnostic reasons.

Coders previously reported 62287 for diagnostic aspiration of a disc, but this code is intended to report therapeutic discectomy only. The language of 62287 was changed slightly to add further clarification regarding code selection.



63620 Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion

In spinal stereotaxis, high dose ionizing radiation is administered in a single fraction to a well defined tumor affecting spinal neural tissue or abutting the dura mater, or to subdural arteriovenous malformations. Its advantages over spinal surgery are twofold: no incision is required and the toxic radiation is precisely delivered only to the defect using three dimensional Computer-aided planning and immobilizing skeletal fixation of the back.

Code 63620 reports the treatment of one spinal lesion. This code replaces 61793, which was deleted for 2009.



64416 Injection(s), anesthetic agent brachial plexus continuous infusion by catheter (including catheter placement)

Catheters can deliver continuous anesthetic to relieve patients postsurgically.

This code once had language that included “daily management for anesthetic agent administration.”This revision reflects a change in the suite of service for these procedures, because they are now often performed on an outpatient basis. Codes 64416, 64446, 64448 and 64449 are affected by this change in language.



64455 Injection(s), anesthetic agent and/or steroid, plantar common digital nerve(s) (eg, Morton’s neuroma)This injection is performed for Morton’s neuroma, a

painful condition that develops secondary to repetitive stress or trauma. Morton’s neuroma occurs in the space between the toes and is commonly treated with steroid injection.

An injection of lidocaine or bupivacaine is sometimes employed to confirm the diagnosis of Morton’s neuroma and provide the patient temporary relief. Code 64455 is reported once per encounter, even if more than one injection is given.



64632 Destruction by neurolytic agent; plantar common digital nerve

Injection of a dilute or alcohol or another neurolyticagent is employed to destroy a plantar nerve, as in the case of Morton’s neuroma, a painful condition that develops secondary to repetitive stress or trauma to the foot.


Ophthalmology Changes for 2009

65756 Keratoplasty (corneal transplant); endothelial

Endothelial keratoplasty describes the removal of the Descemet’s membrane on the inside aspect of the cornea and transplant of this membrane from cadaver cornea.

This procedure is a new technology (only 10 years old) and is seen as a substitute to full-thickness replacement. It differs from other forms of keratoplasty in that it is nonpenetrating(ie, does not cut through the full-thickness cornea), but does provide a therapeutic treatment for the epithelium, which is the layer most commonly affected. Because the procedure is performed from within the anterior chamber, it also carries higher risk than other nonpenetrating forms of keratoplasty.


Ophthalmology Changes for 2009

+65757 Backbench preparation of corneal endothelial allograft prior to transplantation (List separately in addition to code for primary procedure)

The donor cornea must be prepared before endothelial keratoplasty can be performed, and 65757 is used as an add-on code with 65786 to report the backbench services.

The keratoplasty codes were clarified for 2009. Codes for endothelial keratoplasty and backbench prep of the donor corneal tissue were added this year. Previously, backbench work for endothelial keratoplasty would have been reported with unlisted code 66999.


Radiology Changes for 2009

74270 Radiologic examination, colon; contrast (eg, barium) enema, with or without KUB

When there is suspicion of perforation of the bowel or when the viscousness of barium is not optimal for use in an enema, a contrast other than barium is preferred during radiologic examination of the bowel.

For example, gastrografin is an iodinated water soluble contrast enema solution.

This change allows 74270 to be reported when using these other types of contrast.


Radiology Changes for 2009

77785 Remote afterloading high dose rate radionuclide brachytherapy; 1 channel

As medical treatments evolve, so does the language surrounding them. This new code reflects the changing nomenclature of radiation oncology. “High intensity” brachytherapy has been replaced with “high dose rate brachytherapy” and “catheters” have been replaced with “channels.”Revisons also include the deletion of CPT® codes 77781 77784 and a change in the range of channels (catheters) reported with each code. This code reports one channel.


Path / Lab Changes for 2009

83876 Myeloperoxidase (MPO)

The presence of high levels of MPO, a disease-fighting enzyme, is a predictor for myocardial infarction in patients with chest pain. It is released when vascular plaque is unstable.

PrognostiX Inc. has an FDA approved ELISA test kit for MPO concentration, called CardioMPO.

Reporting of an MPO test would have required the use of an unlisted code prior to 2009.



83951 Oncoprotein; des-gamma-carboxy-prothrombin (DCP)

DCP is elevated in chronic liver disease patients at risk for developing hepatocellular carcinoma (HCC). Along with imaging studies and clinical assessment, DCP levels can establish the clinical risks for the patient. HCC is a severe form of carcinoma that results in 10,000 deaths in the United States each year. The use of DCP screening is intended to allow for earlier diagnosis of the disease, when curative treatment will provide better outcomes.

There has been no code specific to DCP prior to 2009. Previously, unlisted codes or 86316 were reported for DCP screening.



85397 Coagulation and fibrinolysis, functional activity, not otherwise specified (eg, ADAMTS 13), each analyte

This test is used in the diagnosis of thromboticthrombocytopenic purpura (TTP) and, to a lesser degree, hemolytic uremic syndrome. TTP is a disorder of blood coagulation that results in organ damage.

Code 85397 is appropriate for reporting TTP diagnostic assays or other functional assays that currently have no specific code.



87905 Infectious agent enzymatic activity other than virus (eg, sialidase activity in vaginal fluid)

Bacterial vaginosis can now be diagnosed while the patient is still in the office, with quick tests including BVBlue, a CLIAwaived test. BVBlue allows for more immediate medical management of the patient’s condition. These tests are performed directly from vaginal swab samples, and will detect gardnerella, bacteriodes, prevotella, and mobilincus. Bacterial vaginosis occurs when the normal balance of bacteria is replaced with an overgrowth of harmful bacteria. It is treated with antibiotics.

This test would have been reported with unlisted code 87999 before 2009.



88720 Bilirubin, total, transcutaneous

This code replaces 88400, deleted for 2009.

This allows for the creation of a new In Vivo subsection for laboratory procedures. Transcutaneous testing is less invasive because the skin remains intact during the procedure. Bilirubin is elevated in patients with jaundice.



88740 Hemoglobin, quantitative, transcutaneous, per day; carboxyhemoglobin

Carboxyhemoglobin forms in red blood cells when carbon monoxide is inhaled, and methemoglobin is a form of hemoglobin that cannot carry oxygen. Both affect the delivery of oxygen to the body. Bilirubin is the yellow by product of blood catabolism, and its high sensitivity to light makes in vivo testing important to the accuracy of testing results.

This code is in a new category entitled “In Vivo (eg, Transcutaneous) Laboratory Procedures.”Code 88400 has been deleted.



88741 Hemoglobin, quantitative, transcutaneous, per day; methemoglobin

Carboxyhemoglobin forms in red blood cells when carbon monoxide is inhaled, and methemoglobinis a form of hemoglobin that cannot carry oxygen. Both affect the delivery of oxygen to the body. Bilirubin is the yellow by product of blood catabolism, and its high sensitivity to light makes in vivo testing important to the accuracy of testing results. This code is in a new category entitled “In Vivo (eg, Transcutaneous) Laboratory Procedures.” Code 88400 has been deleted.


Medicine Changes for 2009

90650 Human Papilloma virus (HPV) vaccine, types 16, 18, bivalent, 3 dose schedule, for intramuscular use

This code reports the supply of HPV vaccine Cevarix, a GlaxoSmithKline product. This drug works similarly to Gardasil, which Merck developed for HPV types 6, 11, 16 and 18. Both vaccines require a regime of three single injections. There are separate codes for the two vaccines because they have different dosing schedules.

There was no code for reporting Cevarix previously. Code 90650 appears in 2009 CPT® with an icon indicating it is pending FDA approval.



90681 Rotavirus vaccine, human, attenuated, 2 dose schedule, live, for oral use

Rotavirus is the leading cause of severe gastroenteritis among children. This code reports the supply of Rotarix for oral administration for infants. A three-dose injection regime for RotaTeqhas been reported with 90680 and remains available for rotavirus administered by injection.

Until 2009, there has not been an oral administration code for rotavirus vaccine.



90696 Diphtheria, tetanus toxoids, acellular pertussisvaccine and poliovirus vaccine, inactivated (DTaP-IPV), when administered to children 4 through 6 years of age, for intramuscular use

Combination vaccines reduce the number of childhood shots, and have become more prevalent. Code 90696 reports pertussis, diphtheria, tetanus, and polio in a single injection for children 4 years through 6 years of age.

Until the change, supply of these antigens would have been reported using separate codes.



90698 Diphtheria, tetanus toxoids, acellular pertussisvaccine, haemophilus influenza Type B, and poliovirus vaccine, inactivated (DTaP–Hib–IPV), for intramuscular use

Combination vaccines reduce the number of childhood shots, and have become more prevalent. Code 90698 reports pertussis, diphtheria, tetanus, and polio and HiB in a single injection.

Previously, supply of these antigens would have been reported using separate codes. This code appears in CPT® 2009 with an icon indicating it is pending FDA approval.



90738 Japanese encephalitis virus vaccine, inactivated, for intramuscular use

Mosquito-borne Japanese encephalitis is a significant health threat in Asia, but rarely seen in the United States. Travelers to Asia receive vaccinations against the virus, but the vaccine has changed over the years.

The existing code 90735 for Japanese encephalitis virus vaccine is for subcutaneous administration. Manufacture of this vaccine has ceased, and the new, intramuscular vaccine will replace it. This new code reflects the new administration route.

If old vaccine is used, report the old code for subcutaneous administration.



Hydration

Codes 90760 - 90779 are deleted for 2009, as the AMA restructures the hydration codes for CPT®so that they appear sequentially to the infusion codes, beginning with 96360


Medicine Changes for 2009 90951 End-stage renal disease (ESRD) related services monthly, for

patients younger than 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, andcounseling of parents; w ith 4 or more face-to-face physician visits per month

Dialysis becomes necessary when kidney disease progresses to a point in which the kidneys are no longer able to function adequately. Chronic kidney failure can continue for as many as 20 years before progressing to end stage renal disease and a need for dialysis. More than 400,000 people in the United States are currently on long term dialysis.

The dialysis codes were changed for 2009 to allow for more consistency between the HCPCS Level II dialysis codes maintainedby CMS and the CPT® dialysis codes. As a result, codes 90918 90925 were deleted. Code 90951 reports services for patients younger than two years. These services always involve parents or guardians, and are more extensive due to the growth and nutritional requirements of infants and toddlers.



93228 Wearable mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events transmitted to a remote attended surveillance center for up to 30 days; physician review and interpretation with report

There are many types of devices used to diagnose or identify heart arrhythmias. Ambulatory event monitors (AEMs) are noninvasive but provide longer periods of monitoring. AEMs can record a “loop”of heart action, erasing past recordings so that the record is limited. These codes report AEM with real time data analysis and transmission, called mobile outpatient cardiac telemetry. Examples of these devices are the CardioNet and the HEARTlink II monitoring devices. Report 93228 for the physician interpretation and review of the AEM report.



93279 Programming device evaluation with iterative adjustment of the implantable device to test the function of thedevice and select optimal permanent programmed values with physician analysis, review and report; single lead pacemaker system

A cardiac pacemaker is implanted to deliver electrical impulses to pace the beats within the patient’s heart. The pacemaker may have one or more leads delivering electricity.

Code 93279 reports the physician’s evaluation and adjustment of the pulses of a single-lead pacemaker.

Codes 93727 - 93736 and 93741 - 93744 are deleted and replaced with 93279 - 93299 for 2009.



93306 Echocardiography, transthoracic, real time with image documentation (2D), includes M mode recording, when performed, complete, with spectral Doppler echocardiography, and with color low Doppler echocardiography

Echocardiography uses the high frequency sound waves of ultrasound to diagnose and evaluate cardiovascular disease. Transthoracicechocardiography can be used to assess the pumping function of the heart, valve competency, and blood flow. Code 93306 reports transthoracic spectral Doppler echocardiography, which records velocity and direction and is useful in diagnosing abnormal blood flow due to regurgitation.

Color Doppler combines spectral Doppler and two-dimensional echocardiography to provide diagnostic imaging on the size and shape of heart structures and the velocity and direction of blood flow. With a color Doppler, the image of blood flowing away fromthe transducer is blue, and the blood flowing toward the transducer is red.



93351 Echocardiography, thansthoracic, real-time with image documentation (2D), includes M-mode recording

Echocardiography uses the high-frequency sound waves of ultrasound to diagnose and evaluate cardiovascular disease. Transthoracic echocardiography can be used to assess the pumping function of the heart, valve competency, and blood flow. Code 93351 reports cardiac stress tests, in which the patient’s heart is elevated during treadmill exertion and an EKG is performed (93015 – 93018). This has been a very successful predictor of CAD among men, but an unsuccessful predictor of CAD among women. More Useful in evaluation of female cardiac health is a stress echocardiogram, in which a cardiac echo is combined with the treadmill exertion.



95010 Percutaneous tests (scratch, puncture, prick) sequential and incremental, with drugs, biologicals or venoms, immediate type reaction, including test interpretation and report by physician, specify number of tests

Allergy skin tests are performed to rule out or quantify allergic reactions to particular substances, including pollens, grasses, venoms, or animals. A commercially prepared solution containing the antigen is placed on the skin, which has been scratched or pricked. The physician evaluates the skin reaction to exposure to the allergen.

The descriptions in CPT® 95010 and 95015 were changed for 2009 to include the physician’s interpretation of the test as well as the report. There is no change to the intent of the codes.



95250 Ambulatory continuous glucose monitoring of interstitial tissue fluid via subcutaneous sensor

Continuous glucose monitoring systems, like the one marketed by MiniMed, measure the interstitial fluid glucose levels of the patient every five minutes. Combined with documentation of exercise, meals, and insulin or oral diabetes medication doses, continuous glucose monitoring provides granularity regarding the patient’s health useful in establishing treatment plans.

A minimum time-frame was added to the description for CPT code 95250 and 95251, as 72 hours is the industry norm, as 72 hours is the industry norm for ambulatory continuous glucose monitoring of this type.



95803 Actigraphy testing, recording, analysis, interpretation and report (minimum of 72 hours to 14 consecutive days of recording)

Actigraphy is the recording of activity and rest during sleep, and is used to determine the quality of rest a patient is experiencing. Typically, the patient wears a device on his wrist that records activity during sleep. The recorded data is downloaded to a computer at the end of the testing cycle of up to two weeks.

Code 0089T (now deleted) previously described actigraphytesting, recording,

and analysis.



95992 Canalith repositioning procedure(s) (eg, Epleymaneuver, Semont maneuver), per day

Canalith repositioning procedures (CRPs) are systematic and therapeutic positionings of the head designed to “roll” a calcium crystal within the convolutions of the semicircular canal. Debris in the canal can cause benign paroxysmal positional vertigo, and rolling the crystal out of the inner workings of the semicircular canal can reduce or eliminate vertigo symptoms. This procedure is unilateral, and may be performed by the physician, audiologist, or physical therapist.

Canalith repositioning would have been reported with an unlisted code prior to 2009.



96360 Intravenous infusion, hydration; initial, 31 minutes to 1 hour

Patients receive intravenous hydration when they are unable to maintain adequate fluid balance. This is usually because the patient is unable to take fluids orally, or because the patient is losing fluids more rapidly than he can replace them orally. Examples include patients who are restricted from drinking prior to surgery, patients with swallowing or GI problems, and patients who have vomiting or diarrhea, or hemorrhage disorders.

Hydrating fluids are prepackaged and may contain sodium chloride or dextrose, but will not contain drugs.

Report 96361 for hydration performed by a clinician and extending from 31 to 60 minutes and replaces code 90760, deleted for 2009.


Category III Changes for 2009

+ 0054T Computer assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on fluoroscopic images (List separately in addition to code for primary procedure)

Imaging for orthopedic surgery provides data that improves outcomes. Codes 20986 and 20987 for image guidance during stereotactic radiosurgery were deleted for 2009.

Code 0054T reports the guidance when performed via fluoroscopic imaging.



+ 0055T Computer assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on CT/MRI images (List separately in addition to code for primary procedure)

Imaging for orthopedic surgery provides data that improves outcomes. Codes 20986 and 20987 for image guidance during stereotactic radiosurgery were deleted for 2009.

Code 0055T reports the guidance when performed via computerized tomography or magnetic resonance imaging.



0184T Excision of rectal tumor, transanal endoscopicmicrosurgical approach (ie, TEMS)

Resection of rectal tumors carries the risk of wound complication, temporary colostomy, and secondary complications due to hospitalization and bed rest, especially in elderly patients. TEMS employs a sigmoidoscopic and laparoscopic diathermy device to treat rectal tumors (most usually, sessile adenomas) in a less invasive manner, and usually requires only one night’s hospital stay. A unique code is needed for this approach because it requires different equipment and expertise, and because the outcomes can vary from more traditional open procedures.



0185T Multivariate analysis of patient specific findings with quantifiable computer probability assessment, including report

Increasingly, physicians are using computer technology to assist in diagnostics. When a computer aided diagnostic (CAD) system is fed pertinent information about the patient, it can assess of the probability, likelihood, or predictive value a diagnosis. This code reports the use of such a system.



0186T Suprachoroidal delivery of pharmacologic agent (does not include supply of medication)

Choroidal neovascularization associated with age related macular degeneration is treated using a cannula to inject drugs (ie, triamcinolone) directly into the space between the sclera and the choroidal layer of the posterior eye. The frequency and quality of intraviteal injection required for this treatment created risks of infection, detachment, and glaucoma, and led to the development of this alterative therapeutic route. While many types of ocular injections are uniquely reported with CPT® codes, none is similar to this type of microcannula delivery.



0187T Scanning computerized ophthalmic diagnostic imaging, anterior segment, with interpretation and report, unilateral

This code has been valid for use for a year, but is only now getting into the code book. The code reports an imaging procedure for anterior segment ocular structures and is used to documented macular and aqueous flow abnormalities.



0188T Remote real-time interactive video-conferencedcritical care, evaluation and management of the critically ill or critically injured patient; first 30 - 74 minutes

This code is intended to capture the time and effort required invideoconferenced patient care, which is becoming more common. This code cannot be used when another physician is reporting critical care codes from the E/M section of CPT®; the new codes are intended to report care provided via videoconference when no other physician is on site providing the patient with critical care E/M service. The physician must have real time access to the physician’s medical record and be able to enter orders into that record.

Documentation of time is also required. Code 0188T reports the first 30 74 minutes of remote critical care E/M.



+0190T Placement of intraocular radiation source applicator (List separately in addition to primary procedure)

This code is reported by the ophthalmologist in conjunction with67036 and reports the use of an applicator to deliver a radioactive source, or in conjunction with a brachytherapycode being reported by the oncologist.

The oncologist applies the radioactive source to the retina while the ophthalmologist holds the applicator in place. When the treatment is completed, the ophthalmologist removes the applicator and closes the wound.



0191T Insertion of anterior segment aqueous drainage device, without extraocular reservoir ; internal approach

This procedure is intended to help control interocular pressure in patients that are not well controlled with medications. In the internal approach, a small stent is placed in the anterior chamber of the eye, through the cornea. The stent supplements existing aqueous flow.

0192T Insertion of anterior segment aqueous drainage device, withoutextraocular reservoir; external approach

This procedure is intended to help control interocular pressure in patients that are not well controlled with medications. In the external approach, the stent is inserted into the anterior segment via the sclera. The stent supplements existing aqueous flow.



0193T Transurethral, radiofrequency micro remodeling of the female bladder neck and proximal urethra for stress urinary incontinence

This procedure is performed on an outpatient basis to improve female urinary continence. A radiofrequency device is deployed into the urethra and positioned within the bladder outlet. Electrodes are deployed into the proximal urethral and the radiofrequency waves are delivered.



0194T Procalcitonin (PCT)

High levels of procalcitonin (PCT) can be indicative of bacterial infections and sepsis, and this test provides early diagnosis of these conditions, and the ongoing monitoring of them. Several tests have been developed for rapid, automated, or manual assay of PCT.



0195T Arthrodesis, pre sacral interbody technique, including instrumentation, imaging (when performed), and discectomy to prepare interspace, lumbar; single interspace

This code represents new approaches and techniques associated with surgeries to L5 S1. AxiaLif is the manufacturer’s name for a system that provides percutaneous access adjacent to the sacral bone. Lumbar fusion is performed with preservation of the annulus and all paraspinal soft tissue structures. It is manufactured by Trans1.


The Goal of Accurate Coding

• Report the codes accurately the very first time

• Have adequate documentation of the need for the service

• Have adequate documentation of exactly what was done

• Have adequate documentation of extenuating circumstances and related services


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To earn CME credits for this course please complete the Evaluation / CME Form and

FAX it back to Economedix within 7 days of the teleconference.

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