New time guidelines, E/M and surgery changes coming as part of CPT update

 Coders will have 212 new CPT® codes for 2011 as a result of the AMA's CPT update. In addition, the AMA revised 106 codes and deleted 110 codes.

The AMA cleaned up CPT by eliminating overlapping or redundant codes, says Jennifer Avery, CCS, CPC-H, CPC, CPC-I, senior regulatory specialist for HCPro, Inc., in Danvers, MA. In addition, it removed some outdated codes because providers no longer perform those procedures. The AMA also created new combination codes to represent a complete procedure and eliminated component coding, similar to the change to radiology coding for 2010.

Look for a large number of resequenced codes. The current codes will remain the same, but the AMA will integrate new code concepts into the existing code families even when sequential code numbers are not available. The AMA uses the “#” to denote resequenced codes and parenthetical notes to identify that the code is in a different section.

Cardiac catheterization and revascularization coding
Some of the biggest changes to the CPT codes this year appear in the cardiac catheterization and revascularization codes.

In the past, coders would report up to three separate codes to describe an endovascular revascularization procedure—one code for the selective catherization, one for the radiology services, and one for the treatment itself. Beginning in 2011, coders will only report one code to represent all of those services.

As a result, the AMA deleted many of the transluminal angioplasty, open transluminal atherectopy, and percutaneous transluminal atherectomy codes. In their place is a new series of codes (37220-37231) to describe the complete procedures. “Those codes are meant to represent not just a small part of the intervention, but the entire procedure—the specific intervention, accessing the vessel, the closure, the catheterization, the imaging, the supervision ,and interpretation,” says Jillian Harrington, MHA, CPC, CPC-P, CPC-I, CCS-P, MHP, president and CEO of ComplyCode in Binghamton, NY.
The AMA also added four add-on codes (37232-37235) and Category III T codes (0234T-0238T).

For cardiac catheterization procedures, the AMA deleted codes 93501-93556 and replaced them with codes 93451-93468. The AMA also made substantial changes to the guidelines for cardiac catheterization and injections.

The new codes contain basically the same information as the old codes, but instead of having separate codes for the components of the procedure, coders will now use one inclusive code, Harrington says. For example, code 93452 includes the left heart catheterization, intraprocedural injection(s) for left ventriculography, and the imaging supervision and interpretation when performed.

Additional surgery changes
The AMA added 62 new codes in the surgery section and revised 55 other codes. As part of the changes, there are extensive revisions to the integumentary system and revisions to the guidelines for skin replacement surgery and skin substitutes.

The major of the integumentary system changes involve debridement. The AMA deleted the codes for skin-only debridement (11040 and 11041). “In order to use the codes in the integumentary section, it needs to go down to the subcutaneous level,” says Harrington.

For skin-only debridement, use revised codes 97579 and 97598. These codes include debridements using high-pressure waterjets; sharp selective debridements with scalpels, scissors, or forceps; and open wound debridements. The AMA revised the codes to include a wider set of techniques for the skin debridement.

Coders may know these codes as physical therapy debridement codes, says Harrington. Sometimes physical therapists performed these services but other times wound care nurses or other practitioners performed the services in a wound care setting.

The AMA removed the word “skin” from the code description of code 11042. Code 11042 now denotes the debridement of the first 20 sq. cm. of subcutaneous tissue. The AMA added a new add-on resequenced code (11045) for each additional 20 sq. cm. of subcutaneous tissue debrided.

You’ll also notice revised wording for codes 11043 and 11044 and new resequenced add-on codes (11046 and 11047) for additional debridement areas.

The musculoskeletal system includes two new codes for anterior interbody approaches for arthrodesis (22552 and 22552). These codes include the discectomy, ostrophytectomy, and decompression of the spinal cord and/or nerve roots. “These are a little more comprehensive than the codes that are already in CPT,” says Harrington.

The AMA also added three new resequenced codes for surgical hip arthroscopy (29914-29916).
In the respiratory section, look for three new codes for endoscopic dilation of the sinus ostia (31295-31297). The difference between the codes comes down to which sinus is being dilated, Avery says.

The AMA also added new guidelines to the sinus endoscopy section to instruct coders that the three new codes include fluoroscopic guidance when performed. The guidelines also identify that the codes represent unilateral procedures. If the provider performs the procedure bilaterally, make sure you append the appropriate modifier.

A new parenthetical note clarifies how to report these codes with other procedures performed on the same sinus during the same session.

AMA added 18 new codes to the digestive system section, including six codes related to repair of a paraesophageal hiatal hernia (43332-43336), three new codes for gastric intubation and aspiration (43753-43755), and two codes for duodenal intubation and aspiration (43756-43757).

Look for eight new codes and nine revised codes in the nervous system. The AMA revised the parenthetical note for intraoperative neurophysiology to state that you should not report code 95920 if the recording is 30 minutes or fewer. If the procedure goes past midnight, you should report the service on the day on which monitoring began. “Be sure to read the parenthetical notes and pay attention to that information to utilize the codes correctly,” Avery says.

In the pain management section, the AMA continued to revise the codes for the extracranial nerves, peripheral nerves, and autonomic nervous system (codes 64455, 64479-64484). The descriptions now make clear that fluoroscopic and CT guidance are included in the service.

The AMA also added a parenthetical note directing coders to use 0228T for ultrasound guidance, which is not included in the code description. “If you are reporting ultrasound guidance, you want to make sure you report that T code,” says Avery. “Even though insurance companies might not recognize those, it’s important to get the data out there.”

The AMA also added new codes for neurostimulators: 64566 for posterior tibia nerves and 64568-64570 for cranial nerves. The codes include placement of both the electrode array and the pulse generator. That makes these codes unique because in other areas, coders could report separate codes for the array and the pulse generator, Avery says. “Now the AMA is starting to look at things more as a system.”

You won’t find code 61795 for stereotaxis any longer. The AMA deleted the code and replaced it with three new add-on codes—61781-61783—that denote the area where the stereotaxis is being used. Be sure to check the exclusionary notes for these codes, says Avery.

Reporting time
In addition to changes to the actual codes, the AMA also revised the introduction of the CPT Manual. The AMA added a new subheading (Time) and guidelines for reporting time. According to Avery, the AMA changed the instruction to:

  • Create general rules for codes that do not specify time rules
  • Define rules for services that start on one calendar date and continue on another
  • Restate that time is considered as face to face unless otherwise specified

Time units are only reported once the midpoint has been passed. For example, at least 31minutes must pass in order to report one hour. “That’s pretty consistent,” Avery says. “We’ve already seen that in the medicine section. We’ve already been practicing that.”

When using time to select an evaluation and management (E/M) code, pick the closest typical time, even if it is less than the time spent on the encounter. In order to report an E/M code based on time, make sure to follow the time rule in the E/M section. Specifically, the provider must spend more than 50% of the visit performing counseling and coordination of care.

If a physician spends 40 minutes with a new patient and more than 50% was spent on coordination of care or counseling, report 99204. However, if the visit lasts for 35 minutes, report 99203.

Remember that you cannot count time twice. Look at the services where time is already factored in and make sure you don’t count that time twice, Avery says.

E/M changes
The AMA added new codes for subsequent hospital observation (99224-99226). These codes match the subsequent hospital care codes that are already in use. The new codes are “per day” codes to report additional days of observation services and should not be reported on the same day as the initial observation care or discharge services. Multiple physicians (e.g., attending physician, surgeon) may report these codes for their E/M services of an observation patient. Do not report these codes on the same day as an office or ED visit.

To learn more about the new CPT codes for 2011, order HCPro’s audio conference “CPT 2011: Overview of Major Code Changes” on-demand. E-mail your questions to Senior Managing Editor Michelle A. Leppert, CPC-A, at mleppert@hcpro.com.