CPT2012 - Quick list of coding changes

Hopefully this new year will bring all of you good fortune.  CPT & HCPCS have some changes in store for us...  Here's a quick list of what you should be on the look-out for.   When in doubt - always read and re-read your guidelines that CPT provides for us...   and HAPPY CODING!

Evaluation and Management

• Clarification to the wording of prolonged service description removes the term physician and removes face to face language for inpatient codes (Medicare may still require face to face)
• Clarification that 99356 should be used in inpatient or observation setting
• Time component added to CPT codes 99218-99220 Initial Observation

 
New Medicare screening/counseling codes 

G0446 –Intensive Behavioral Therapy for Cardiovascular Disease
G0444- Screening for Depression in Adults
G0449- Annual Obesity Screening
G0447- Intensive Behavioral Therapy for Obesity
G0442- Annual alcohol misuse screening
G0443- Behavioral counseling for alcohol misuse

Medicare Annual Wellness visit-
Now includes requirement for Health Risk assessment

Medicare Telehealth services revised to include Emergency department & smoking cessation codes

• G0425 Initial inpatient or emergency department telehealth consultation, typically 30 minutes communicating with the patient via telehealth
• G0426 Initial inpatient telehealth or emergency department consultation, typically 50 minutes communicating with the patient via telehealth
• G0427 Initial inpatient or emergency department telehealth consultation, typically 70 minutes or more communicating with the patient via telehealth
• Smoking cessation codes 99406, 99407, G0436 and G0437 have been added to the list of covered Telehealth services

CPT Surgery Section: 


Surgery-

Integumentary- Many codes in the skin grafting and skin substitute replacement
have been deleted and replaced with new codes

• 15170-15176 and 15300-15431 have been deleted
• New codes 15271-15278 have been added

Musculoskeletal-

• Two new codes have been added 22633 and 22634 to describe arthrodesis with a combined posterior and posterolateral technique and posterior interbody technique
• New codes and revisions to 29581-29583 Application of multi-layer compression system
• 29581-ankle and foot
• 29582-thigh and leg
• 29583-upper arm and forearm
• Arthroscopy knee revision codes to 29880 and 29881 to include same or multiple compartments

Respiratory System

• Multiple revisions and new codes including 32096, 32098, 32505, 32056, 32507 thoractomy codes and 32601-32674 for new VATS codes (video assisted thoracic surgery)

Cardiovascular System

• Multiple revisions to the pacing and Cardioverter-Defibrillator codes 33002-33249 along with nine new codes
• Multiple revisions to revascularization codes

Digestive System -

• Abdominal Paracentesis codes 49080 and 49081 have been deleted and replaced with three new codes
• 49082-abdominal paracentesis without image guidance
• 49083- abdominal paracentesis with image guidance
• 49084-Peritoneal lavage including image guidance

Gynecology & OB Services -
No major changes for 2012 -  but the below integumentary codes are used in OB/GYN offices and have been changed.

• 11975 and 11977 insertions of contraceptive capsules have been deleted,
• use 11981 to report insertion and 11976 for removal

Nervous System-

• Destruction of paravertrebral facet joint code 64622-64627 have been deleted.  
• Nnew codes were added to specify location:
• 64633-64634- destruction with image guidance cervical or thoracic
• 64635-64636- destruction with image guidance lumbar or sacral

• Codes 64553, 64565, 64575-64585 Neurostimulator electrode codes have beenrevised to add language of "array"

Radiology Section -

Deletions:

• Insertion pacemaker, fluoroscopy and radiography, radiological supervision and interpretation;
  
  • 73542 Radiological examination, sacroiliac joint arthrography, radiological supervision and interpretation;
• 75722 Angiography, renal, unilateral, selective (including flush aortogram), radiological supervision and interpretation;
• 75724 Angiography, renal, bilateral, selective (including flush aortogram), radiological supervision and interpretation;
• 75940 Percutaneous placement of IVC filter, radiological supervision and interpretation;
• 
  
  • 77079 appendicular skeleton (peripheral) (eg, radius, wrist, heel)
  • 77083 Radiographic absorptiometry (eg, photodensitometry, radiogrammetry), 1 or more sites;
  • 78223 Hepatobiliary ductal system imaging, including gallbladder, with or without pharmacologic intervention, with or without quantitative measurement of gallbladder function;
  • 78584 Pulmonary perfusion imaging, particulate, with ventilation; single breath
  • 78585 Pulmonary perfusion imaging, particulate, with ventilation; rebreathing and washout, with or without single breath
  • 78586 Pulmonary ventilation imaging, aerosol; single projection
  • 78587 multiple projections (eg, anterior, posterior, lateral views)
  • 78588 Pulmonary perfusion imaging, particulate, with ventilation imaging, aerosol, 1 or multiple projections;
  • 78591 Pulmonary ventilation imaging, gaseous, single breath, single projection;
  • 78593 Pulmonary ventilation imaging, gaseous, with rebreathing and washout with or without single breath; single projection
  • 78594 multiple projections (eg, anterior, posterior, lateral views)
  • 78596 Pulmonary quantitative differential function (ventilation/ perfusion) study;
  
  ADDTIONS:
  
  
  • 74174 Computed tomographic angiography, abdomen and pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing
  • 77424 Intraoperative radiation treatment delivery, x-ray, single treatment session
  • 77425 Intraoperative radiation treatment delivery, electrons, single treatment session
  • 77469 Intraoperative radiation treatment management
  • 78226 Hepatobiliary system imaging, including gallbladder when present;
  • 78227 Hepatobiliary system imaging, including gallbladder when present; with pharmacologic intervention, including quantitative measurement(s) when performed
  • 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
   

Radiology services "T" codes and Unlisted code additions

• 93998 Unlisted noninvasive vascular diagnostic study

• 0274T Percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy), any method, under indirect image guidance (eg, fluoroscopic, CT), with or without the use of an endoscope, single or multiple levels, unilateral or bilateral; cervical or thoracic

• 0275T Percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy), any method, under indirect image guidance (eg, fluoroscopic, CT), with or without the use of an endoscope, single or multiple levels, unilateral or bilateral; lumbar

• 0282T Percutaneous or open implantation of neurostimulator electrode array(s), subcutaneous (peripheral subcutaneous field stimulation), including imaging guidance, when performed, cervical, thoracic or lumbar; for trial, including removal at the conclusion of trial period

• 0283T Percutaneous or open implantation of neurostimulator electrode array(s), subcutaneous (peripheral subcutaneous field stimulation), including imaging guidance, when performed, cervical, thoracic or lumbar; permanent, with implantation of a pulse generator

• 0284T Revision or removal of pulse generator or electrodes, including imaging guidance, when performed, including addition of new electrodes, when performed

• 0285T Electronic analysis of implanted peripheral subcutaneous field stimulation pulse generator, with reprogramming when performed

Laboratory Services-

• Multiple new lab codes added to report genetic testing

Medicine Services Section-

• Code 90470 administration of H1N1 vaccine has been deleted
• Pulmonary Function test codes 94240, 94260, 94350, 94360, 94370 have been deleted

 New codes added  for the Medicine section

• 94726-Plethysmography for determination of lung volumes and airway resistance
• 94727 Gas dilution or washout for lung volumes and distribution of ventilation abd closing volumes
• 94728-Airway resistance by impulse oscillometry
• +94729-Diffusing capacity (add on code)
• New needle electromyography  add-on codes + 95885-95887 are  to be used with nerve conduction studies

New HCPC's

• G0450- Screening for sexually transmitted infections, includes laboratory tests for Chlamydia, Gonorrhea, Syphilis and Hepatitis B
  
  
• New modifier-PD -Diagnostic or related non-diagnostic item or service provided in a wholly owned or operated entity to a patient who is admitted as an inpatient within 3 days—changes to Medicare 72 hour rule go in to effect July 1st, 2012.

Telemedicine: bringing healthcare to rural areas.

Telemedicine has made inroads into the medical area, by bringing specialist care to very rural areas, anywhere in the world.  This type of technology allows a two-way real-time communication between the rural provider and a specialist consultation that is not nearby.

Telemedicine has provided many benefits to those in a rural setting, to have access to specialty care throughout the world.

Coding for telemedine is a new challenge.  CMS (Medicare) will pay for selective telehealth/telemedicine services.  CMS states that they will reimburse for the use of a telecommunication as a substitute for a face-to face encounter.  However, they will only reimburse if the ‘originating’ site is in a rural health professional shortage area (HPSA).  Telemedicine is considered investigational by some 3^rd party carriers, and may not be reimbursed.  If that is the case, then the patient would ultimately be responsible for those charges. 

Payment and coverage of telemedine/telehealth services requires an interactive audio and video telecommunication system that allows real-time processing with communication between the provider at the rural health site, and the provider (consultant) at the distant location. 

Below is a listing of the type of services utilizing telemedicine/telehealth.  This is not an all-inclusive listing.

§    Office/outpatient office visits

§    Individual psychotherapy

§    Pharmacologic management

§    Psychiatric diagnostic interview examinations

§    End Stage Renal Disease Services (ESRD)

§    Medical Nutrition Therapy

§    Radiology Interpretation Services

§    Cardiac medicine services

For coding of these services HCPCS provides the most comprehensive listing of service codes to be reported.  However, modifiers also play a part in this too.  As a coder if you are reporting with HCPCS the listing below is a methodology to report consultations, and follow up services in an inpatient setting.

G0406	Follow-up inpatient telehealth consultation, limited, physicians typically spend 15 minutes communicating with the patient via telehealth (new 1-1-2009)
G0407	Follow-up inpatient telehealth consultation, intermediate, physicians typically spend 25 minutes communicating with the patient via telehealth (new 1-1-2009)
G0408	Follow-up inpatient telehealth consultation, complex physicians typically spend 35 minutes communicating with the patient via telehealth (new 1-1-2009)
G0409	Social work and psychological services, directly relating to and/or furthering the patient's rehabilitation goals, each 15 minutes, face-to-face; individual (services provided by a CORF qualified social worker or psychologist in a CORF) (new 1-1-2009)
G0425	Initial inpatient telehealth consultation, typically 30 minutes communicating with the patient via telehealth (new 1-1-2010)
G0426	Initial inpatient telehealth consultation, typically 50 minutes communicating with the patient via telehealth (new 1-1-2010)
G0427	Initial inpatient telehealth consultation, typically 70 minutes or more communicating with the patient via telehealth (new 1-1-2010)
Q3014	Telehealth originating site facility fee
T1014	Telehealth transmission, per minute, professional services bill separately

If you are in the outpatient setting you need to use the modifiers GT & GQ.

       GQ  Via asynchronous telecommunications system

GT  Via interactive audio and video telecommunication system

As a provider of telehealth services, a GT modifier will need to be appended to the professional fee code (either CPT code(s)  or HCPCS code).  These modifier codes would be added to the standard evaluation and management codes, or to what would normally be billed for a visit that is an actual face-to-face visit with the provider. 

If the evaluation service includes a provider reviewing the medical record(s), then no separate billing may be submitted for a record review.  Medical record review is already included in consultation/evaluation services per CPT guidelines.

If the telecommunications service is provided by asynchronous telecommunications, then the GQ modifier would need to be appended.  An example of the asynchronous technology is a service such as an ultrasound, or MRI performed, then sent to a distant location/provider for interpretation/consultation.  This technology is not actual real time face to face, but “store and forward” for use by the consultant. 

In some cases an insurance payer will pay for the usage of the telecommunication equipment if you are the originating site.  Billing for this service, can be submitted with HCPCS code Q3014 on your claim form.  In addition, some carriers may even pay for telehealth transmission “per minute” by usage of HCPCS Code T1014. 

At this time, telemedicine is still a relatively new process and new codes are emerging all the time. This link below is very helpful -   

http://www.americantelemed.org/files/public/policy/Medicare_Payment_Of_Services.pdf 

HAPPY CODING!!

What is involved in Maternal/Fetal Ultrasound Coding

 

Let’s start at the beginning…

In the world of Obstetrics, Maternal Fetal Medicine (MFM)/Perinatology is a sub-specialty that is focused on the fetus, and it’s growth during the pregnancy.  Perinatology specialists work closely with obstetricians, and genetic counselors to provide care for high risk pregnancies, and to provide screening services for potential fetal anomalies prior to birth.  The perinatal period, is generally defined as the time from 8-12 weeks gestation to approximately 30-45 days after delivery.

MFM/perinatal specialists can provide extensive care for high risk pregnancies, to include such diagnoses as multiple gestation (twins, triplets etc) , in-vitro fertilization pregnancies, advanced maternal age,  and chronic maternal diagnoses (i.e. hypertension, diabetes) . Perinatologists can also perform and provide extensive ultrasound procedures with interpretation of fetal growth and/or anomalies, placenta location, amniotic fluid, and umbilical cord complications during the pregnancy.  They also can provide highly complex surgical fetal procedures performed in-utero.

Coding for obstetric ultrasound can be challenging.  CPT has specific guidelines for each ultrasound code, yet the documentation and interpretation of these codes can be difficult to figure out when looking at the actual documentation or interpretation of the scans. 

CPT has outlined the obstetrical codes within the code series  76801 through 76828.  Not only do these codes include traditional ultrasound, but also include fetal biophysical profiles, doppler velocimetry of the fetal umbilical and middle cerebral artery but also echocardiography of the fetus.

Many Perinatologists practice in their own office, and have their own ultrasound equipment.  If the scan is provided in the office setting,  a global ultrasound code would be billed.  However, in locations that a perinatologist is not readily available, patients will have the scans performed in an outpatient facility.  If that is the case, the facility will bill the ultrasound with a TC (technical component only) modifier.  The facility will forward the scans, to the perinatologist to provide an interpretation of the scan.  The perinatologist will only bill for the written report or interpretation of the scan by adding the 26 (interpretation only) modifier to the cpt code. 

Conquering the Ultrasound code-set

According to the guidelines in CPT all diagnostic ultrasounds require both a permanently recorded image and a final written report.  A coder needs to fully understand if they are billing and coding ultrasound scans as A) Global or complete scan; B)the recorded image or Technical component only, or C) the interpretation/documentation only of the ultrasound scan.

Below are more helpful hints to coding Obstetrical ultrasounds:

§    Review the code definitions to determine if the CPT code itself specifies for the first or single gestatation – such as found in code 76801

§    If the add-on code “Ì” symbol is denoted at the beginning of the CPT code, do not use a 51 modifier with the code, as per the CPT definitions of a ‘add on code’.  Review code 76802 to understand the add on code is used to denote ‘each additional gestation”   

§    If the CPT code set does not specify ‘units”   such as in the code 76815, it states 1 or more fetus’s so only 1 unit would be appropriate.  It should not be billed as 2 units. Only as 1 unit, even though more than 1 fetus may be documented.

§    If the CPT code set does not specify ‘units” as in code 76816, CPT informs the coder to add the modifier 59 for each additional fetus when reporting  If coding for twins, the codes reported would be 76816 for baby a, and 76816-59 for baby b.

§    Review codes carefully to determine if a trimester has been specified within the ultrasound codeset such as in code 76805

§    Review to determine if the ultrasound is performed trans-abdominally, or trans-vaginally. 

Deciphering the Terminology

In MFM/Perinatology medicine, there are many strange words and procedures, that a coder should understand before trying to decipher an ultrasound documentation.  Included below are terms commonly found in MEM/perinatology ultrasound documentations.

Term	Abbreviation	Definition
Amniocentesis	Amnio	A procedure to draw a sample of amniotic fluid which is then analyzed to detect chromosome abnormalities, structural defects and metabolic disorders.
Amniotic Fluid	Amnio Fluid	The fluid in which the embryo or fetus is suspended within the womb (the embryonic sac inside the uterus).
Beats per minute	bpm	the number of heartbeats per unit of time (beats per minute)
Chorionic Villus Sampling	CVS	An alternative to amniocentesis to detect chromosomal abnormalities. The CVS can be performed earlier in fetal development than amniocentesis, and thereby allows earlier diagnosis.
Congenital Defect		A problem or condition existing at or dating from birth; acquired during development in the womb (uterus) and not through heredity
Crown Rump Length	CRL	the ultrasound measurement of a fetus
Fetosocopy		A minimally-invasive examination of the fetus by a miniature video camera inserted through a small tube
Estimated Date of Confinement	EDC	a term for the estimated delivery date for a pregnant woman
Fetal Abnormality		A condition detected in the unborn human that is not the normal or average.
Fetal Echocardiography		A high resolution ultrasound test to detect heart abnormalities in the fetus.
Fetal Pole		a thickening on the margin of the yolk sac of a fetus during pregnancy
Genetic Counseling		Medical guidance concerning inherited (genetic) disorders.
In Utero		Relating to being in the womb
Intra-Uterine Pregancy	IUP	the normal location for a pregnancy to occu
In-vitro Fertilization	IVF	a process by which egg cells are fertilized by sperm outside the body
Last Menstrual Period	LMP	the first day of the menstrual period prior to conceiving, used to calculate Expected Date of Delivery
Magnetic Resonance Imaging	MRI	A noninvasive diagnostic technique that produces computerized images of internal body tissue induced by the application of radio waves
Maternal Fetal Medicine	MFM	The testing and management of high-risk pregnancies; also called perinatology
Neonatal Intensive Care Unit	NICU	An area within a hospital dedicated to the care and treatment of pre-term and   critically ill babies
Neural Tube Defect	NTD	an opening in the spinal cord or brain that occurs very early in human development, visualized by ultrasound
Nuchal Translucency	NT	The area around the neck of the fetus, also known as the nuchal fold
Postnatal		Occurring, existing or performed after birth
Prenatal		Occurring, existing or performed before birth
Trans-abdominal ultraound	TAUS	Ultrasound procedure performed to visualize the pelvic cavity through application of sound waves by a device placed upon the abdomen
Trans-Vaginal ultrasound	TVUS	Ultrasound procedure performed to visualize the cervix and uterine contents by application of sound waves through a device inserted into the vagina.
Trimester		the division of pregnancy into three-month sections
Ultrasound	U/sound	A technique involving the formation of a 2D-or 3D dimensional image used for the examination and measurement of bodily abnormalities.

What the documentation reports look like

Included below is a dictation that shows the correct coding and documentation for a twin pregnancy.  Review and test yourself on the codes to be applied.  This documentation was performed as a global procedure in the perinatologists office

ULTRASOUND EXAMINATION:

The LMP of this 30 year old, G1, P0-0-0-0 patient was unknown, her working

EDC is MAR 8 2011 and the current gestational age is 11 weeks 2 day(s) by

date of assisted reproductive procedure. A sonographic examination was

performed on AUG 19 2010.

A normal gestational sac was documented. The yolk sac was seen, measuring

0.4 cm. The amnion was also documented. A normal fetal pole was noted with

cardiac motion at 169 bpm.

EXAM INDICATIONS:

1) 1st Trimester Screening    2) Twins    3) IVF

CPT Coding: 76801   +76802

Diagnosis Code(s)  651.03

***************************************************************************

FETUS A EXAMINATION:

GENERAL RESULTS:

Fetus # 1 of 2

Variable presentation

Fetal growth appeared normal

Placenta Location = Posterior

No placenta previa

Placenta Grade = 0

Amniotic Fluid = Normal

FETAL MEASUREMENTS:

* Indicates Measurement Included In Average Gestational Age

CRL 4.5 cm c/w 11 weeks 1 day(s)*

THE AVERAGE GESTATIONAL AGE is 11 weeks 1 day(s) +/- 7 days.

ANATOMY DETAILS:

Visualized, Appearing Sonographically Normal:

STOMACH, BLADDER, PLACENTA

Suboptimal:

RIGHT KIDNEY, LEFT KIDNEY

UTERUS/ADNEXA

The uterus was visualized, midplane in orientation.

IMPRESSION:

Twin IUP (Fetus A)

11 weeks 2 day(s) by date of assisted reproductive procedure. (EDC= MAR 8

2011)

11 weeks 1 day(s) by this ultrasound. (EDC= MAR 9 2011)

Variable presentation

Fetal growth appeared normal

Chorionicity = Dichorionic, Diamniotic

RECOMMENDATIONS:

Repeat ultrasound in one week.

****************************************************************************

FETUS B EXAMINATION:

GENERAL RESULTS:

Fetus # 2 of 2

Fetal growth appeared normal

Placenta Location = Posterior

No placenta previa

Placenta Grade = 0

Amniotic Fluid = Normal

FETAL MEASUREMENTS:

* Indicates Measurement Included In Average Gestational Age

CRL 5.2 cm c/w 11 weeks 5 day(s)*

THE AVERAGE GESTATIONAL AGE is 11 weeks 5 day(s) +/- 7 days.

ANATOMY DETAILS:

Visualized, Appearing Sonographically Normal:

STOMACH, BLADDER, PLACENTA

Suboptimal:

RIGHT KIDNEY, LEFT KIDNEY

UTERUS/ADNEXA

The uterus was visualized, midplane in orientation. The left ovary was

enlarged, measuring 7.6 x 5.9 x 7.0 cm. The right ovary was enlarged,

measuring 6.1 x 5.5 x 4.0 cm.

IMPRESSION:

Twin IUP (Fetus B)

11 weeks 2 day(s) by date of assisted reproductive procedure. (EDC= MAR 8

2011)

11 weeks 5 day(s) by this ultrasound. (EDC= MAR 5 2011)

Fetal growth appeared normal

Chorionicity = Dichorionic, Diamniotic

RECOMMENDATIONS: COMMENTS:

Patient is seen for first trimester screening.

The CRL is at the lower limits for the NT measurement and it could not be obtained on either twin given patient habitus. Thus patient will need to return for the serum screen and NT measurement. Sequential screening was discussed in detail with regard to the 2 step testing process. Screening for a NTD is only provided when the second serum screen is completed. Cystic fibrosis screening was also discussed. At the conclusion of the discussion, patient wished to return for the NT and serum screen.

Repeat ultrasound in one week.

CPT	Diagnosis
76801	651.03 V28.3
+76802