3871-REV-121013 - Exhibit A5 - final · 5 Presented By: Denise Williams, RN, CPC-H, is senior vice...

1

2

Copyright Information

Copyright © 2013 HCPro.

The “2014 CPT Code Changes Explained” materials package is published by HCPro., a division of BLRFor more information, please contact us at: 75 Sylvan Street, Suite A-101, Danvers, MA 01923.

Attendance at the webcast is restricted to employees, consultants, and members of the medical staff of the Licensee. The webcast materials are intended solely for use in conjunction with the associated HCPro webcast. The Licensee may make copies of these materials for internal use by attendees of the webcast only. All such copies must bear the following legend: Dissemination of any information in these materials or the webcast to any party other than the Licensee or its employees is strictly prohibited.

In our materials, we strive to provide our audience with useful and timely information. The live webcast will follow the enclosed agenda. Occasionally, our speakers will refer to the enclosed materials. We have noticed that non-HCPro webcast materials often follow the speakers’ presentations bullet by bullet and page by page. However, because our presentations are less rigid and rely more on speaker interaction, we do not include each speaker’s entire presentation. The enclosed materials contain helpful resources, forms, crosswalks, policies, charts, and graphs. We hope that you will find this information useful in the future.

Although every precaution has been taken in the preparation of these materials, the publisher and speaker assume no responsibility for errors or omissions, or for damages resulting from the use of the information contained herein. Advice given is general, and attendees and readers of the materials should consult professional counsel for specific legal, ethical, or clinical questions.

HCPro , a division of BLR, is not affiliated in any way with The Joint Commission, which owns the JCAHO and Joint Commission trademarks; the Accreditation Council for Graduate Medical Education, which owns the ACGME trademark; or the Accreditation Association for Ambulatory Health Care (AAAHC).

3We will begin shortly!

If you are not hearing music or you are experiencing any technical difficulties, please

contact our help desk at 888-364-8804.

4

5

Presented By:

Denise Williams, RN, CPC-H, is senior vice president for Health Revenue Assurance Associates, Inc., in Plantation, Fla. She has more than 20 years of healthcare experience, including history as a clinical nurse in cardiopulmonary, oncology, and med-surgery; Medicare and third-party payer compliance for a multihospital system; and chargemaster coordination for two multihospital systems. Williams has participated as a member of patient financial services work groups, provider communication groups with Medicare fiscal intermediaries, and clinical task forces to create and standardize internal charging processes and standardize the processes across multihospital systems. She is a member of the Provider Roundtable, a group of providers across the country that advises CMS regarding implications of regulatory changes to providers as well as the technical aspects of implementing regulations. Williams is a member of the HCPro editorial advisory board for the APC Weekly Monitor.

6

Presented By:

Joanne Schade-Boyce, BSDH, MS, CPC, ACS,AHIMA-Approved ICD-10-CM/PCS Trainer, is director of education and curriculum for Health Revenue Assurance Associates, Inc., in Plantation, Fla., and has vast experience as a clinician, educator, insurance director, business administrator, lecturer, and consultant. She has over 30 years of experience in healthcare administration with a Master of Science, its focus on Education & Management, from Old Dominion University. Schade-Boyce has been a lead instructor of educational courses for over 25 years, as well as an expert in development of user-friendly training and instructional manuals. Her areas of expertise include surgical coding, compliance monitoring, external coding audits, on- and off-site training of surgical coding and billing, as well as extensive experience utilizing and coding with the new ICD-10-CM and PCS systems.

7

Agenda

Major CPT changes by body system. New, revised, and deleted codes for:

• Complex wound repair

• Breast procedures and imaging

– New comprehensive codes for biopsy with placement of devices and imaging of the specimen

– New codes for placement of localization devices performed without image-guided biopsy

• Soft tissue procedures

• Removal of “malignant tumor” references and use of “sarcoma” for radical resection codes

• New codes for removal of prosthesis, including debridement and synovectomy

• Cardiovascular section

– New section for endovascular repair of aorta (FEVAR)

– New comprehensive codes for placement of endovascular stents (arterial and venous)

– New comprehensive codes for vascular embolization and inclusion

8

Agenda (cont.)

• Digestive system/gastroenterology

– New introductory and parenthetical notes for sections

– New codes for ERCP

– New instructions and specificity to endoscopy codes

– Nomenclature changes

• Urology

– New combination code

• Chemodenervation

– New codes for neck muscle, larynx

– New section for chemodenervation of extremity, including introductory guidelines

• Radiology

– Deletion of imaging components that are now included in the complete procedure codes (e.g., endovascular stents, placement of breast localization devices)

– Update to introductory guidelines for radiation simulation

9

Agenda (cont.)

• Molecular pathology – New Molecular Pathology Table

– New tests added to Tier 2 procedures

• Laboratory codes– New codes for specific therapeutic drug assays

• Medicine section

– New vaccine codes

– Gastroenterology

– Speech/otorhinolaryngology

– Cardiology and EP studies

– Nomenclature changes and revisions

– Active wound management

• Category III codes

• Live Q&A

10

Reminders

• Important reminders – Following this session – Proceed to your 2014 CPT

books to read the complete narrative and inclusive instructions regarding new and revised CPT codes

– Work with your departments regarding some of the “unique” new/revised codes specific to their services:

• Clinically – they can assist with moving forward the understanding and documentation required to support revenue

– Revenue and future rate setting under OPPS:

• As AMA bundles services into one comprehensive CPT code, you must bundle your resources and set your charges accordingly to provide clean data with stabilization, if not growth, for rate setting in the future

11

CPT 2014 Errata

• First things, first: Make sure your CPT

books are as up to date as possible!

• For a full list of corrections for 2014 CPT, go to:

– http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/cpt/about-cpt/errata.page

12

CPT 2014 Theme

• The year of Delete … NO wait … Replace CPT codes!

• The year of “The Plumber” with lots of changes in the GI section; and promises of “The Thunder from Down Under” for next year.

• The year of analysis “Paralysis” with lots of additional chemodenervation codes!

13

CPT 2014 Theme

• AND, an extension of the year of bundlingparentheticals with LOTS of “DO NOT REPORT with…” language!

– AND on that note – ensure your narratives within your charge structure match as closely as possibly to CPT narratives to avoid charge errors

14

Parenthetical Notes

• They are listening … there are many, many, many new and updated parenthetical notes for 2014

– Requests from coders and third-party payers for clarifications on what codes can be reported together and how to report the codes together

– Based on suggestions from coders regarding items that required further explanation

15

Parenthetical Notes

– Reciprocal notes have been added

• Example:

• Note for 64617 = Do not report 64617 in conjunction with 95873, 95874

• Note for 95873 and 95874 states not to report the code with 64617

• All are found in the electronic version of the book; may not be in the printed version

16

ACME Presenters …

17

EVALUATION & MANAGEMENT

2014 Updates

18

• Pretty straightforward and not what we thought/feared it would be:

– A few new codes:

• Elevated Cat III codes for Hypothermia

• New subsection under Non-Face-to-Face Services section, guidelines and 4 new codes for interprofessional/Internet consultations

Evaluation & Management

19

• Revised codes with editorial changes to:

– Hospital discharge codes parenthetical

– Pediatric Critical Care Patient Transport guidelines

– Complex Chronic Care Coordination Services

– Transitional Care Services guidelines


20


• Hospital Discharge Services– The parenthetical following CPT code

99239 has been revised to:• Adhere to the CPT Nomenclature

Reporting Neutrality initiative policy (aka politically correct language started last year with the introduction of “qualified health care professional”); and

• Clarify the reporting of concurrent care services.

• Bottom line: Status indicator (B)

21


• New subheading under Non-Face-to-Face section for Interprofessional Telephone/Internet Consultations (99446–99449)

– What is it?

• Assessment and management services by a physician with specific specialty expertise, offered in complex or urgent situations, or due to geographic distance

22


• Telephone/Internet Consults (cont.)

– Very specific reporting requirements:

• Timing is an important element to these codes. Below are just a few:

– Specialty-specific physician must not have seen patient within 14 days

– Cannot accept transfer of care until after the telephone/Internet consultation

– Must be new patients, or an established patient with a new problem, but the 14-day rule applies

23



– Timing elements continued:

• Greater than 50% of the time reported must be devoted to medical consultation via verbal/Internet

• If telephone/Internet consultations are less than 5 min, not reportable

• Only one code should be reported

– Parentheticals in abundance here, so please READ

24



– Parentheticals in abundance here, so please READ

• Bottom line: Historically, CMS doesn’t recognize consult codes for hospitals. These are no exception:

– Status indicator (E)

25


• List of New Telephone/Internet Codes: 99446 Interprofessional telephone/Internet assessment and management

service provided by a consultative physician including a verbal and written report to the patient’s treating/requesting physician or other qualified health care professional; 5-10 minutes of medical consultative discussion and review

99447 11-20 minutes of medical consultative discussion and review

99448 21-30 minutes of medical consultative discussion and review

99449 31 minutes or more of medical consultative discussion and review

# 99481 Total body systemic hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)

# 99482 Selective head hypothermia in a critically ill neonate per day (List separately in addition to code for primary procedure)

26


• Inpatient Neonatal & Pediatric Critical Care (99468–99476):

– Guideline revisions to clarify reporting time includes only the communication between the supervising physician and transport team members; as well as what may be reported separately

27


• Inpatient Critical Care (cont.):

– Two new add-on codes

• 99481 – Total body systemic hypothermia in a critically ill neonate

• 99482 – Selective head hypothermia in a critically ill neonate

– Bottom line: SI (C) – Inpatient only

28


• Complex Chronic Care Coordination Services (99487–99489):

– Review the guideline revisions for clarity to what is included in the care plan, reporting requirements, etc.

–Bottom line: These are SI (N) –packaged codes, so no dough!

29


• Transitional Care Management Services (99495–99496):

– Introduced in 2013 and revisions in the guidelines were made for 2014 to offer clarity to its applicability to new patients, timing of reporting E/M services, explanation of discharge services not constituting as the required face-to-face visit, etc.

• Bottom line: SI (V) / APC 0632 ~ $96

30

ANESTHESIA SECTION NO UPDATES

2014 Updates

31

SURGERY SECTION 2014 Updates

32

INTEGUMENTARY SYSTEM2014 Updates

33

Integumentary System

• Overview of changes:

– Editorial changes to code descriptions

– Deletion of complex repair code due to medically unlikely scenarios

– Breast surgery code revisions … again

34


• Introduction and Removal

– Addition of CPT code:

• 10030: Image-guided fluid collection drainage by catheter (e.g., abscess, hematoma, seroma, lymphocele, cyst), soft tissue (e.g., extremity, abdominal wall, neck), percutaneous

– This code was established to report the bundled service of image-guided fluid collection drainage by catheter for percutaneous soft tissue

– Status indicator (T) and assigned to APC 0006

35


• Introduction and Removal

– Addition of CPT code 10030:

• Parenthetical notes:

– Directing user to report the code for each individual collection drained with a separate catheter

– Reminding user to not report specific imaging codes because imaging is inclusive

– Directing user to CPT codes 49405–49407 for image-guided fluid collection drainage that is percutaneous or transvaginal/transrectal of visceral, peritoneal, or retroperitoneal

36


• Repair – Complex:– Deletion of CPT code 13150- Repair,

complex, eyelids, nose, ears and/or lips; 1.0 cm or less

• After RUC (Relative Value Scale Update Committee) review, this code was deemed medically unlikely and therefore deleted

– Due to the elements required to perform a complex repair, 1.0 cm or less was judged too small to possibly comply with requirements of the code guidelines

• Watch for reactive parentheticals where 13150 might have been mentioned

37


• Parenthetical revisions to add-on code 15777- Implantation of biologic implant (e.g., acellular dermal matrix) for soft tissue reinforcement (i.e., breast, trunk) (List separately in addition to code for primary procedure):

– The “e.g.” has been changed with “i.e.” to clarify that this code is exclusively for the reporting of implantation of biologic implant for the breast and trunk only!

– New parenthetical directing user to 17999 for biological implants for soft tissue reinforcement other than breast or trunk.

38


• CPT code 15777

http://i1.ytimg.com/vi/2KcXt3dJI_w/hqdefault.jpg

39

Bit about “e.g.” vs. “i.e.”

When to Use How to Test

i.e.

When you’re adding extra information to clarify something that was previously stated. This information is finite, meaning the only possibilities are the things you list after the “i.e.”

Replace with “in other words”

e.g.

When you’re listing examples of something you stated previously. Using “e.g.” means there are more possibilities than the ones you’re stating.

Replace with “for example”

40


• Breast procedures – Can we all say, “bundled procedures”?

41


• Breast procedures are “lumped” into 3 main categories:

– Biopsies without imaging guidance

– Biopsies with imaging guidance andplacement localization devices

– Image-guided placement of localization devices without image-guided biopsies

42


• Breast Excision:

– Biopsies without imaging guidance, reported with CPT codes:

• 19100 – Biopsy, percutaneous, needle core, not using imaging guidance


• 19101 – Biopsy, open, incisional


43


• Breast Excision:

– Biopsies with imaging guidance andplacement localization devices; six (6) new bundled codes that include:

• Breast lesion biopsy

• Marker placements

• Specimen radiography if performed

• Categorized by stereotactic guidance, ultrasound guidance, and MRI guidance

• Each has a corresponding add-on code for additional lesions subject to biopsy

44


• First, note – the deletions:19102 percutaneous, needle core, using imaging

guidance19103 percutaneous, automated vacuum assisted or

rotating biopsy device, using imaging guidance

45


• Now, note – the replacements: 19081 Biopsy, breast, with placement of breast localization device(s) (eg, clip,

metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including stereotactic guidance

19082 each additional lesion, including stereotactic guidance (List separately in addition to code for primary procedure)

19083 Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including ultrasound guidance

19084 each additional lesion, including ultrasound guidance (List separately in addition to code for primary procedure)

19085 Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including magnetic resonance guidance

19086 each additional lesion, including magnetic resonance guidance (List separately in addition to code for primary procedure)

46


• OPPS 2014 Breast Procedure Payment:

CPT Short Descriptor SI APC RWPayment

Rate

19081 Bx breast 1st lesion strtctc T 0005 9.6609 $702.08

19082 Bx breast add lesion strtctc N

19083 Bx breast 1st lesion us imag T 0005 9.6609 $702.08

19084 Bx breast add lesion us imag N

19085 Bx breast 1st lesion mr imag T 0005 9.6609 $702.08

19086 Bx breast add lesion mr imag N

47


• Clinical vignette for code 19081 offered by 2014 CPT Changes:

– A 63-year-old asymptomatic female has a new indeterminate microcalcification in the UOQ of right breast. A biopsy is performed using stereotactic guidance.

48


• Clinical vignette (cont.):– A small incision is made with a scalpel.

Periodic imaging is obtained and reviewed to ensure that the biopsy device is accurately positioned. Once needle position is verified, the needle is “fired.” Needle position is verified with an additional stereotactic pair of images. The vacuum system is activated; multiple samples of tissue are removed. Once the tissue is removed, the biopsy device is partially withdrawn; the biopsy bed is stereotactically imaged to evaluate for sample adequacy.

49


• Clinical vignette (cont.):– A radiograph of the specimen samples is

obtained to confirm sampling adequacy. The physician repeats this scenario until convinced that an adequate sample has been obtained for the pathologist. Once complete, a marker is placed into the breast through the stereotactic needle system to mark the biopsy site. Stereotactic images are obtained after marker deployment. The needle is withdrawn and hemostasis is obtained and incision closed.

50


• Introduction:

– Image-guided placement of localization devices without image-guided biopsiesare reported with eight (8) new bundled codes that are categories by:

• Mammographic guidance, stereotactic guidance, ultrasound guidance, MRI guidance

• Each has a corresponding add-on code for additional lesions localized

51


• First, note – the deletions:

19290 Preoperative placement of needle localization wire, breast;

19291 each additional lesion (List separately in addition to code for primary procedure)

19295 Image guided placement, metallic localization clip, percutaneous, during breast biopsy/aspiration (List separately in addition to code for primary procedure);

52


• More bundling ahead …

53


• Now, note – the replacements: 19281 Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle,

radioactive seeds), percutaneous; first lesion, including mammographic guidance

19282 each additional lesion, including mammographic guidance (List separately in addition to code for primary procedure)

19283 Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including stereotactic guidance

19284 each additional lesion, including stereotactic guidance (List separately in addition to code for primary procedure)

19285 Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including ultrasound guidance

19286 each additional lesion, including ultrasound guidance (List separately in addition to code for primary procedure)

19287 Placement of breast localization device(s) (eg clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including magnetic resonance guidance

19288 each additional lesion, including magnetic resonance guidance (List separately in addition to code for primary procedure)

54


• OPPS 2014 Breast Procedure Payment:

CPT Short Descriptor SI APC RWPayment

Rate

19281 Perq device breast 1st imag Q2 0420 1.3520 $98.25

19282 Perq device breast ea imag N

19283 Perq dev breast 1st strtctc Q2 0420 1.3520 $98.25

19284 Perq dev breast add strtctc N

19285 Perq dev breast 1st us imag Q2 0420 1.3520 $98.25

19286 Perq dev breast add us imag N

19287 Perq dev breast 1st mr guide Q2 0420 1.3520 $98.25

19288 Perq dev breast add mr guide N

55


• Clinical vignette for codes 19283/19284 offered by 2014 CPT Changes:– A 52-year-old female recently underwent

stereotactic biopsy of two separate lesions within the inferior right breast. One region demonstrated ductal carcinoma in-situ (DCIS), and the second was diagnosed as invasive ductal carcinoma. Stereotactic-guided wire/needle localization of the focus of DCIS is performed after initial stereotactic-guided marker localization of separate invasive ductal carcinoma.

56


• Clinical vignette for codes 19283/19284:– The needle is advanced to stereotactic

coordinates. Placement is confirmed with stereotactic images. The marker is deployed. Stereotactic images are obtained after marker deployment (19283). Post-marker placement images are reviewed for successful deployment. The process is repeated as needed to place markers at additional locations around the periphery of same lesion (19284). Images are annotated. Markers are secured, as needed.

57


• Salient parentheticals:

– When more than one biopsy or localization device placement is performed using the same imaging modality, use an add-on code

– If additional biopsies are performed using different imaging modalities, report another primary code for each additional modality

58


• Salient parentheticals:

– When an open incisional biopsy is performed after image-guided placement of a localization device, 19101 is reported and the appropriate image-guided localization device placement code is reported

59

Integumentary SystemPolling Question

• Relative to the last parenthetical, why aren’t we directed back to the bundled biopsy codes 19081–19086?

A. The decision to perform the procedure was decided after the localization, so mutually exclusive

B. It’s an editorial boo-boo

C. The biopsy wasn’t performed percutaneously

D. Wile E. Coyote finally outsmarted the Road Runner

60

MUSCULOSKELETAL SYSTEM

2014 Updates

61

Musculoskeletal System

• Revised introductory guidelines for:– Excision of subcutaneous soft tissue

tumors; and

– Radical resection of soft tissue tumors

• Revised codes for soft tissue excision of:– Head & neck & Thorax

– Back & Flank

– Abdomen

– Shoulder

62


• Revised codes for soft tissue excision of (cont.):

– Humerus (upper arm) & elbow

– Forearm and/or wrist area

– Hand or fingers

– Pelvis and hip area

– Thigh & knee area

– Foot or toe

63


• New codes for:

– Removal of foreign body of shoulder (deep)

– Removal of prosthesis of humeral and/or glenoid

• Newly added cross-references

64


• Review all introductory guidelines, including the definitions for “closed treatment,” “open treatment,” and “percutaneous skeletal fixation”

• Pay particular attention to the changes made to the “Excision of subcutaneous soft connective tissue tumors” and “Radical resection of soft connective tissue tumors”

65


• Rationale for the introductory guideline changes to “Excision of subcutaneous soft tissue tumors”:– There was a need to clearly indicate

that these codes are to be reported for connective tissue tumors and further instructs users to report the integumentary codes 11400–11446 for the excision of benign lesions of cutaneous origin (e.g., sebaceous cyst)

66


• For example, under the section for Neck (Soft Tissues) and Thorax, the following changes are noted under Excision:

21555 Excision, tumor, soft tissue of neck or anterior thorax, subcutaneous; less than 3 cm

#21552 3 cm or greater

(For excision of benign lesions of cutaneous origin [eg, sebaceous cyst], see 11400-11426)

67


• For example, under the section for Shoulder, the following changes are noted under Excision:

23077 Radical resection of tumor (eg, malignant neoplasm sarcoma), soft tissue of shoulder; less than 5 cm

23078 5 cm or greater

(For radical resection of tumor[s] of cutaneous origin [eg, melanoma], see 11600-11620)

68


• Introduction or Removal changes:

– A bit about implants vs. prosthesis:

• Implant is something the surgeon puts into MS system, it’s not a replacement and it’s consider to be load sharing

69


• Introduction or Removal changes:

– A bit about implants vs. prosthesis:

• Prosthesis replaces an anatomical structure and it’s consider to be load bearing

70


• Introduction or Removal changes:– Shoulder Prosthesis:

• There was a need to distinguish between the removal of a foreign body vs. removal of a prosthesis of the shoulder to ensure that the work value for the physician is appropriately weighed; given the changes in technology and the difficulties that it presents

– Changes in cementing techniques prove it more difficult and time-consuming—to place as well as remove

– Specialized equipment is needed to avoid bone loss or fracture and allow for complete removal of cement to prevent infection

71


• Introduction or Removal changes:– Shoulder Prosthesis:

• Therefore, codes 23331 & 23332 have been deleted and three (3) new codes established:

– 23333 Removal of foreign body deep (subfascial or intramuscular)

» SI (T) and assigned to APC 0020

– 23334 Removal of prosthesis, includes debridement and synovectomy when performed; humeral or glenoid component

» SI (T) and assigned to APC 00202

– 23335 humeral and glenoid components (e.g., total shoulder)

» SI (C) – Inpatient status only

72


• Introduction or Removal changes:– Humerus (Upper Arm) and Elbow:

• Revised code 24160 to read:

(To report removal of foreign body, elbow, see 24200, 24201)

(To report removal of hardware from distal humerus or proximal ulna, other humeral and ulnar prosthesis, use 20680)

(Do not report 24160 in conjunction with 24370 or 24371 if a prosthesis [i.e., humeral and/or ulnar component(s)] is being removed and replaced in the same elbow during the same surgical session)

24160 Removal of prosthesis, includes debridement and synovectomy when performed; humeral and ulnar components

24164 radial head

73


• Humerus (Upper Arm) and Elbow:

– Inquiring minds want to know – how did CMS revise code 24160?

2013 2014Status Indicator T Q2

APC 0050 0050

RW 32.3471 35.4456

Payment Rate $2306.77 $2575.90

74

RESPIRATORY SYSTEMMinor updates – review all parentheticals

2014 Updates

75

CARDIOVASCULAR SYSTEM2014 Updates

76

Fenestrated Endovascular Repair of Aorta (FEVAR)

• New section and guidelines

• Category III codes (0078T–0081T) deleted and replaced with Category I codes (34841–34848)

• Visceral aorta – Upper abdominal aorta that contains the celiac, superior mesenteric, and renal arteries

77

FEVAR

• New codes 34841–34848 describe placement of fenestrated endovascular graft in the visceral aorta either alone or in combination with the infrarenal aorta

• Codes define the total number of visceral and/or renal arteries requiring placement of endoprosthesis through an aortic endograft fenestration

78

FEVAR

• The device resembles a pair of pants:– Requires normal artery above and below

the targeted area

– Seals off the aneurysm and depressurizes the area

• The fenestrated main body endoprosthesis is placed within the visceral aorta

• FEVAR expands the ability to treat because open procedure not required

79

FEVAR

• Fenestrated grafts have a hole cut in the graft to match an artery that doesn’t need to be sealed or to allow passage of catheters/stents into another vessel

• “Scallop” of a graft is just cutting a “divit” in the graft for fitting and does not mean it is fenestrated

80

FEVAR

Fenestrated endoprosthesis

81

FEVAR

http://www.hopkinsmedicine.org/healthlibrary/test_procedures/cardiovascular/abdominal_aortic_aneurysm_repair_92,P08291

https://www.vascularweb.org/vascularhealth/Pages/endovascular-stent-graft.aspx

http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/DeviceApprovalsandClearances/Recently-ApprovedDevices/ucm300704.htm

82

FEVAR

• Code selection is based on: – Number of fenestrations in the visceral

segment

– Whether the device extends into the common iliac arteries or terminates in the aorta above the aortic bifurcation

• Other interventional procedures performed at the time of FEVAR may be reported separately (e.g., embolization, IVUS)

83

FEVAR

• New codes

• 34841 – Endovascular repair of visceral aorta … by deployment of a fenestrated visceral aortic endograft and all associated RSI, including target zone angioplasty, when performed; including one visceral artery endoprosthesis (superior mesenteric, celiac or renal artery)

• 34842 – including two visceral artery endoprostheses …

• 34843 – including three visceral artery endoprostheses

• 34844 – including four or more visceral artery endoprostheses

• These codes describe use of endoprosthesis from the visceral aorta with the distal end still in the infrarenal aorta

84

FEVAR

• New codes

• 34845 – Endovascular repair of visceral aorta and infrarenal abdominal aorta ... with fenestrated visceral aortic endograft and concomitant unibody or modular infrarenal aortic endograft …; including one visceral artery endoprosthesis

• 34846 – including two visceral artery endoprostheses

• 34847 – including three visceral artery endoprostheses

• 34848 – including four or more visceral artery endoprostheses

• These codes describe use of a fenestrated endoprosthesis from the visceral aorta through the infrarenal aorta into the common iliac arteries

85

Transcatheter Stent Placement

• New code

• 37217 – Transcatheter placement of intravascular stent(s), intrathoracic common carotid artery or innominate artery by retrograde treatment via open ipsilateral cervical carotid artery exposure, including angioplasty, when performed and RSI

• Includes:

– Open surgical exposure and standard suture closure (cervical carotid artery)

– All retrograde access and catheterization of the vessel

– Traversing the lesion

86


• Includes (cont.)

– RSI directly related to the intervention (i.e., diagnostic angiogram)

– Imaging performed to document performance and completion of the intervention (i.e., stenting and angioplasty)

• Previously reported with unlisted code 37799

87


• Deleted codes 37205–37208 and 75960

• Identified as being reported together on claims 75% of the time

• Replaced with all-inclusive codes specific to artery or vein

• New introductory guidelines for this section (Endovascular Revascularization -Open or percutaneous transcatheter)

88


• New codes• 37236 – Transcatheter placement of an intravascular

stent(s) (except lower extremity, cervical carotid, extracranial vertebral or intrathoracic carotid, intracranial, or coronary), open or percutaneous, including RSI and including all angioplasty within the same vessel when performed, initial artery

• 37237 – each additional artery (List separately in addition to code for primary procedure)

• 37238 – Transcatheter placement of an intravascular stent(s), open or percutaneous, including radiological supervision and interpretation and including angioplasty within the same vessel, when performed; initial vein

• 37239 – each additional vein (List separately in addition to code for primary procedure)

89


• Cannot report these codes for bare metal or covered stents placed into visceral branches within the endoprosthesis target zone

• Cross-reference notes for reporting stents in other vessels

• Multiple stents placed in single vessel may only be reported with a single code

– Codes defined as “per vessel”

90


• All codes include:– All balloon angioplasty

– Pre-dilation (even if failed PTA and stent is required)

– Post-dilation following stent placement

– Treatment of lesion outside stent but in same vessel

– Use of larger and/or smaller balloon to achieve therapeutic results

– RSI directly related to the procedure

– Closure of arteriotomy by pressure, application of arterial closure device or standard suture closure

– Imaging performed to document completion of the intervention

91


• Procedures reported separately:– Angioplasty in a separate vessel

– Non-selective and/or selective catheterization

– Extensive repair/replacement of an artery

– US guidance for vascular access

– IVUS

– Mechanical thrombectomy

– Thrombolytic therapy

– Treatment of additional, different vessel(s) during same session

• Use additional vessel codes

92

Vascular Embolization Procedures

• Deleted codes 37204–37208, 37210

• Identified as being reported with 75894 and 75898 on claims 75% of the time

• Replaced with all-inclusive codes

93

Vascular Embolization and Occlusion Procedures

• New codes • 37241 – Vascular embolization or occlusion inclusive of all

radiological supervision and interpretation, intraprocedural roadmapping and imaging guidance necessary to complete the intervention; venous, other than hemorrhage (e.g., congenital or acquired venous malformation, venous and capillary hemangiomas, varices, varicoceles)

• 37242 – Vascular embolization or occlusion, inclusive …; arterial, other than hemorrhage or tumor (e.g., congenital or acquired arterial malformations, arteriovenous malformations, arteriovenous fistulas, aneurysms, pseudoaneurysms)

• 37243 – Vascular embolization or occlusion, inclusive …; for tumors, organ ischemia or infarction

94


• New code • 37244 – Vascular embolization or occlusion, inclusive …;

for arterial or venous hemorrhage or lymphatic extravasation

• Excludes the central nervous system, head and neck procedures, ablation and sclerotherapy procedure for venous insufficiency/telangiectasia of extremities/skin

95


• Include moderate sedation

• Do not include:

– Vessel selection and catheter placement(s)

– US guidance for vascular access

– Diagnostic studies (e.g., angiography)

– Chemotherapy administration

– Injection of a radioisotope

96


• New extensive introductory guidelines

• Potential overlap for placement of vascular stents and embolizations

– If stent is placed as conduit for deploying embolization coils, report the embolization code only

– If stent is deployed as the only management of the situation, then report the stent procedure

97

All Inclusive Codes

• It is imperative that the charges and costing of all-inclusive codes be carefully reviewed and considered

98

HEMIC & LYMPHATIC SYSTEMSMinor updates – review all parentheticals

2014 Updates

99

DIGESTIVE SYSTEM2014 Updates

100

Digestive System

• Try to keep up …

101

Digestive System

• So many changes in this section that in the time we have we can’t review all of them; therefore, salient changes will be reviewed and discussed

• The listeners are encouraged to follow along in their CPT books for note taking, and the presenters recommend CPT Changes: An Insider’s View for a thorough explanation of all the changes in this section

102

Digestive System

• Big picture– GI Endoscopy in three (3) subsections:

• Esophagoscopy (43191–43233) – 13 new/14 revised/2 deleted codes

• Esophagogastroduodenoscopy (EGD) (43235–43259)

– 5 new/21 revised/2 deleted codes

• Endoscopic Retrograde Cholangiopancreatography (ERCP) (43260–43273)

– 5 new/4 revised/5 deleted codes

103

Digestive SystemPolling Question

• Why so many changes?A. Language doesn’t reflect current

technologyB. Wile E. Coyote couldn’t wiggle his way

out of the updatesC. Out of date for current techniques and

devicesD. CPT trying to align with ICD-10 diagnosis

codesE. CMS requested a review of physician

work and practice expenseF. All of the above

104

Digestive System

• Endoscopy section– Review section guidelines with the

addition of instructions relative to controlling bleeding:

• “Control of bleeding that occurs as a result of the endoscopic procedure is not separately reported during the same operative session”

– Anatomic structures that are included in an esophagoscopy are now specified (this will assist with ICD-10-CM coding)

105

Digestive System

• Endoscopy section– Separate procedures:

• Parent codes 43191, 43197, 43200, 43235, and 43260:

– May not be reported in conjunction with the other codes in their respective family of codes

– The procedures described in the parent code are inherently included in the other services

» The “separate procedures” designation is used throughout the code set to designate services/procedures that are normally included in another procedure(s), considered an integral component of another procedure, but are appropriately reported only when performed independently from other procedures

106

Digestive System

• Esophagoscopy anatomy– First, review the language in the

definition of Esophagoscopy:

• Esophagoscopy has been specifically defined to include examination from the cricopharyngeus muscle (upper esophageal sphincter) up to and including the gastroesophageal junction and may include examination of the proximal region of the stomach via retroflexion when performed

107

Digestive System

• Now, take note of language changes in code descriptions. Take a look at Esophagoscopy codes:– Rigid, Transoral (43191–43196)– Flexible:

• Transnasal (TNE) – NEW Code: 43197 – Esophagoscopy, Diagnostic

– NEW Code: 43198 – Esophagoscopy, Biopsy

» Status indicator (T) and assigned to APC 0141

• Transoral– 43200–43232 previously described rigid or

flexible, now just flexible

108

Digestive System

• Esophagoscopy– Moderate sedation:

• Rigid Transoral and Flexible Transnasal procedures do NOT include moderate sedation

– Codes: 43191–43196, 43197, 43198

• Flexible Transoral procedures DO include moderate sedation

– Codes 43200–43232

109

Digestive System

• Second, take note of language changes in code descriptions. For example:

43191 Esophagoscopy, rigid, transoral; diagnostic, including collection of specimen(s) by brushing or washing when performed (separate procedure)

43200 Esophagoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)

110

Digestive System

• Esophagogastroduodenoscopy (EGD):

– Note the introductory language directing the user back to esophagoscopy codesif only the esophagus up to the proximal region of the stomach is examined

– Added parenthetical directing user to use codes 43233, 43235–43259, 43266, 43270 for examination of a surgically altered stomach where the jejunum is examined distal to the anastomosis [e.g., gastric bypass, Billroth II]

111

Digestive System

• EGD:– Parallel language to a discontinued

colonoscopy added to EGD:• To report esophagogastroscopy where the

duodenum is deliberately not examined[e.g., judged clinically not pertinent], or because of significant situations preclude such exam [e.g., significant gastric retention precludes safe exam of duodenum], append modifier 52 if repeat examination is notplanned, or modifier 53 if repeat examination is planned

– AMA Symposium statement: OPPS modifier 74 in lieu of modifier 53

112

Digestive System

• EGD:

– Parallel language to a discontinued colonoscopy added to EGD:

• DOCUMENTATION IMPACT

– Physicians will have to CLEARLY explain why the examination wasn’t completed – meaning, CLEARLY document initial intent (to perform an EGD), all structures examined, and why duodenum wasn’t examined

113

Digestive System

• Opinion – the number of out-of-sequence codes might have you bleary-eyed …

114

Digestive System

• Let’s begin – Endoscopy section– Endoscopic Mucosal Resection (EMR):

• Parallel concepts across esophagoscopy and EGD

• Previously reported with Cat III codes or unbundled codes

• All techniques involve:

– Identification & demarcation of lesion

– Submucosal injection

– Endoscopic snare resection

• EMR can include injection-assisted, cap-assisted, and ligation-assisted techniques

115

Digestive System

• Endoscopy section

– Endoscopic Mucosal Resection (EMR):

http://www.hopkinsmedicine.org/gastroenterology_hepatology/_pdfs/esophagus_stomach/gastric_cancer.pdf

116

Digestive System


– Endoscopic Mucosal Resection (EMR):

• TONS of parenthetical notes associated with these codes. Review ALL of them as they were written to assist with the use of these codes.

• “If you don’t inject, you can’t resect”

117

Digestive System

• Endoscopy section– Esophagoscopy/EMR summary:

• Previously reported using:– 43201 Injection

– 43205 Band ligation

– 43217 Snare

• NEW CODE: 43211 Esophagoscopy, flexible, transoral; with endoscopic mucosal resection

• Do NOT report 43211 and 43202 (biopsy) if performed on the same lesion

• Status indicator (T) and assigned to APC 0141

118

Digestive System

• Endoscopy section– EGD/EMR summary:

• Previously reported using:– 43236 Injection

– 43244 Band ligation

– 43251 Snare

• NEW CODE: 43254 EGD, flexible, transoral; with endoscopic mucosal resection

• Do NOT report 43254 and 43239 (biopsy) if performed on the same lesion

• Status indicator (T) and assigned to APC 0141

119

Digestive System

• Endoscopy section– Stent Placement:

• Parallel concepts across esophagoscopy, EGD and ERCP

• Previous codes 43219, 43256, 43268 deleted

• New codes added that include pre- and post-dilation and guidewire passage:

– 43212 – Esophagoscopy

– 43266 – EGD

» (SI (T) and APC 0384)

– 43274 – ERCP

» Includes sphincterotomy

» (SI (T) and APC 0151)

• Code 43241 was revised for consistency

120

Digestive System

• Stent Placement example:– Have a look:

• Esophagus with stent placement– Previously reported using:

» 43219 - Stent

» 43220 - Dilation or

» 43226 - Dilation over guidewire

– NEW code: 43212 Esophagoscopy, flexible, transoral; with placement of endoscopic stent (includes pre- and post-dilation and guidewire passage, when performed)

(Do not report 43212 in conjunction with 43220, 43226)

121

Digestive System

• Stent Placement example:

– Have a look:

122

Digestive System


– Dilation:

• Parallel concepts across esophagoscopy and EGD:

– 43220 and 43249

» Revised to specify transendoscopic Balloon dilation less than (not equal to) 30 mm diameter

» 43220 – Esophagoscopy

» 43249 – EGD

123

Digestive System


– Dilation:

• NEW code: 43213 Esophagoscopy, retrograde (from below, up) dilation:

– Fluoroscopic guidance is included

– Code 43456 was deleted

• Rare procedure

– Performed in children or a severely restricted esophagus

124

Digestive System

• Endoscopy section– Dilation:

• NEW codes: 43214 and 43233– Added for upper esophagoscopy with Balloon

Dilation 30 mm or larger in diameter

– 43214 – Esophagoscopy

– 43233 – EGD

– Fluoroscopic guidance is included

• High-risk procedure– Common diagnosis is achalasia – inability to

move food down the esophagus

– The procedure ruptures the fibers making the esophagus unable to close, but comes with a high-risk of perforation

125

Digestive System


– Dilation:

• Revised code: 43245 EGD, gastric outlet dilation:

– Revised to describe dilation of gastric/duodenal strictures

– Guidewire example removed from description

126

Digestive System


– Control of Bleeding:

• Parallel concepts across esophagoscopy and EGD:

– 43227– Esophagoscopy

– 43255 – EGD

– Review all parentheticals for all the “go-withs” and “not go-withs” codes

127

Digestive System


– Ablation:

• Parallel concepts across esophagoscopy EGD and ERCP:

– Deleted codes: 43228, 43258, 43272

– Ablation codes now include pre- and post-dilation, and guidewire passage, if performed

– New codes:

» 43229 – Esophagoscopy

» 43270 – EGD

» 43278 – ERCP

128

Digestive System

• Esophagoscopy and EGD

– Watch for when fluoroscopy is “bundled” and when is isn’t. For example:

• Fluoroscopy IS separately reportable:

– 43226 – Esophagoscopy, guide wire insertion with dilation

• Fluoroscopy is NOT separately reportable:

– 43233 – EGD, balloon dilation >30mm

129

Digestive System

• ERCP– Review all the changes to include:

• Revised codes and language to better reflect current medical terminology and/or standard of care

• For example:– 43263 – reference to “pancreatic duct or

common bile duct” removed

– 43264 – language revised to include removal of calculi/debris from duct(s)

– 43265 – language revised to include destruction of calculi/debris

130

Digestive System

• ERCP– Review all the changes to include:

• New codes:– 43274 – Stent placement

– 43275 – Foreign body or stent removal

– 43276 – Removal and exchange of stents

» Reported per stent, use modifier 59

– 43277 – Balloon dilation

– 43278 – Ablation

• Deleted codes: 43267, 43269, 43271, and 43272

131

Digestive System

• Esophagus EUS

– Ask yourself these questions:

• What was endoscoped?

• What did EUS examine?

– Only Esophagus:EUS Code Short Descriptor Extent of EUS Exam

43231 Esophagoscopy with EUS Esophagus

43232 Esophagoscopy with EUSand FNA

Esophagus

132

Digestive System

• EUS (cont.):

– EGD:

EUS Code Short Descriptor Extent of EUS Exam

43237 EGD with EUS Esophagus, stomach, or duodenum and adjacent structures

43238 EGD with EUSand FNA

Esophagus, stomach, or duodenum and adjacent structures

133

Digestive System

• EUS (cont.):

– EGD:


43242 EGD with EUSand FNA

Esophagus, stomach, and either duodenum orsurgically altered stomach where the jejunum is examined

43259 EGD with EUS Esophagus, stomach, and either duodenum orsurgically altered stomach where the jejunum is examined

134

Digestive System

• EUS (cont.):

– EGD:


43240 EGD with pseudocyst and EUS

Esophagus, stomach, or duodenum and adjacent structures

43253 EGD with EUS and transmural injection

Esophagus, stomach, and either duodenum orsurgically altered stomach where the jejunum is examined

135

The END of Digestive System

• Aspirin, anybody?

136

URINARY SYSTEM2014 Updates

137

Urinary System

• Minor changes with addition of one new code and changes to parentheticals, especially in the Ureter and Pelvis section:– New code: 52356

#52356 Cystourethroscopy; with lithotripsy including insertion of indwelling ureteral stent (e.g., Gibbons or double-J type)(Do not report 52356 in conjunction with 52332, 52353 when performed together on the same side)

Status indicator (T) and assigned to APC 0429

138

MALE & FEMALE SYSTEMSMinor updates – review all parentheticals

2014 Updates

139

ENDOCRINE SYSTEMNO UPDATES

2014 Updates

140

Meanwhile, back in the desert …

Wile E. Coyote is planning his next attack …

141

NERVOUS SYSTEM2014 Updates

142

Chemodenervation

• Chemodenervation is the chemical “silencing or interruption” of a nerve or group of nerves

• A nerve sends a signal down a pathway

• Chemodenervation happens when this pathway is “interrupted” after injecting a chemical, such as botulinum neurotoxin

143

Chemodenervation

• Deletion of code 64613 which described multiple uses of chemodenervation of the neck muscles

• Injecting the neck muscles vs. injecting the larynx:

– Specific codes reflect specificity and intensity of injecting the larynx

144

Chemodenervation

• New code 64616 – Chemodenervation of muscle(s); neck muscle(s), excluding muscles of the larynx, unilateral (e.g., for cervical dystonia, spasmodic torticollis)– Append modifier 50 for bilateral procedure

– For guidance by EMG or muscle electrical stimulation, see 95873 and 95874

– Do not report more than one guidance code for any unit of 64616

145

Chemodenervation

• New code 64617 – Chemodenervation of muscle(s); larynx, unilateral, percutaneous (e.g., for spasmodic dysphonia), includes guidance by needle electromyography, when performed

– Append modifier 50 for bilateral procedure

– For diagnostic needle EMG of the larynx, see 95865

146

Chemodenervation

• Why a specific code for the larynx?

– Allows more specificity and captures the intensity of the service

– Includes localizing EMG as this percutaneous procedure virtually always performed with EMG control

• Unilateral procedure but includes all muscles that might be injected

• Includes local-topical anesthesia if used

147

Chemodenervation

• Deletion of code 64614 due to lack of specificity

• Six new codes – 64642–64647• 64642 – Chemodenervation of one extremity; 1–4

muscle(s)

• 64643 ; each additional extremity, 1–4 muscle(s)

• 64644 – Chemodenervation of one extremity; 5 or

more muscles

• 64645 ; each additional extremity, 5 or more

muscles

148

Chemodenervation

• Report 64642, 64643, 64644, 64645 once per extremity based on number of muscles injected, not the number of injections

• Maximum number of units = 4 per patient:

– Report only one base code (64642, 64644) per session

– Report one unit of additional extremity code(s) (64643 or 64645) for each additional extremity injected

• AMA Errata corrected language

149

Chemodenervation

• Amount and name of drug injected should be clearly documented along with specificity regarding the muscles that were injected

150

Chemodenervation

• Examples from AMA Symposium presentation:– 1 injection into each limb

• 64642 x1; 64643 x3

– 5 injections into each limb • 64644 x1; 64645 x3

– 3 injections in LUE and LLE; 5 injections in RUE and RLE

• 64642 x1; 64643 x1; 64644 x1; 64645 x1

151

Chemodenervation

• Updated parenthetical notes for 64615 (Chemodenervation of muscle(s); muscle(s) innervated by facial, trigeminal, cervical spinal and accessory nerves, bilateral [e.g., for chronic migraine])

For guidance see 95873, 95874. Do not report more than one guidance code for 64615.

152

Chemodenervation

• New codes

– 64646 – Chemodenervation of trunk muscle(s); 1–5 muscles

– 64647 – 6 or more muscles

• Report either 64646 or 64647 once per session

153

EYE & AUDITORY SYSTEMSMinor updates – review all parentheticals

2014 Updates

154

DIAGNOSTIC RADIOLOGY2014 Updates

155

Diagnostic Radiology

• Revised description:

– 72040 – Radiologic examination, spine, cervical; 2 or 3 views

– Changed from “3 views or less”

– For clarification as code exists for one view (72020)

156


• Deleted code – 75960

– Transcatheter introduction of intravascular stent(s) (except coronary, carotid, vertebral, iliac, and lower extremity artery), percutaneous and/or open, radiological supervision and interpretation, each vessel

157

Diagnostic Radiology75960 (cont.)

• CPT 75960 appeared 75% of the time with endovascular revascularization procedures (CPT codes 37205–37208)

• Now included in new therapeutic service codes (37236–37239) for transcatheter placement of stents

• Many new parenthetical notes due to new combination/all-inclusive service codes

158


• New parenthetical note for 77002 (fluoroscopic guidance for needle placement)

77002 is included in all arthrography radiological supervision and interpretation codes. See Administration of Contrast Material(s) introductory guidelines for reporting of arthrography procedures.

– CMS screens for high expenditures

159


• Deleted codes 77031 and 77032:

– Stereotactic and MRI guidance for breast procedures

– Included in new comprehensive codes for services (19081, 19283, 19281)

160

Radiation Therapy

• Updated introductory guidelines concerning Simulation

• Complex if any of these criteria are met:

– Particle, rotation, or arc therapy

– Complex or custom blocking

– Brachytherapy simulation

– Hyperthermia probe verification

– Any use of contrast material

161

Radiation Therapy

• Complexity defined by number of treatment areas:

– Simple – one treatment area

– Intermediate – two treatment areas

– Complex – three or more treatment areas

• Treatment area – contiguous anatomic location that will be treated with radiation therapy

162

Radiation Therapy

• New code – 77293 – Respiratory motion management simulation (List separately in addition to code for primary procedure)– Simulations not always done on single

day as the process may spread over several days

– Add-on code; must be billed on same date of service as 77295 and 77301 (radiotherapy plans)

163

Radiation Therapy

• Revised code – 77295

– 3-dimensional radiotherapy plan, including dose-volume histograms

– Does not represent simulation – moved to Medical Radiation Physics section

164

LABORATORY SERVICES2014 Updates

165

Therapeutic Drug Assays

• New codes for specific drugs

– 80155 – Caffeine

– 80159 – Clozapine

– 80169 – Everolimus

– 80171 – Gabapentin

– 80175 – Lamotrigine

– 80177 – Levetiracetam

– 80180 – Mycophenolate (mycophenolic acid)

166

Therapeutic Drug Assays

– 80183 – Oxcarbazepine

– 80199 – Tigabine

– 80203 – Zonisamide

• All studies are quantitative

– Testing is not limited to a specific method

• Use for any quantitative method of identification

• Material may be from any source

167

Yep, MO’ MOPath

Beep Beep

168

Molecular Pathology

• New Table added for Molecular Pathology codes:– Abbreviated Gene Name

– Full Gene Name

– Commonly Associated proteins/diseases

– Applicable CPT code(s)

• Located at the beginning of the Laboratory section of CPT book

169

Molecular PathologyTier 1

• Tier 1 – Specific Analytes

– New parenthetical notes for how to report 81228 and 81229 if analysis is not genome-wide, analyte-specific

– New code

• 81287 – MGMT (0-6-methylguanine-DNA methyltransferase) e.g., glioblastoma multiforme), methylation analysis

170

Molecular PathologyTier 1 (cont.)

– Revised codes for HLA:

• 81371, 81376, 81382

• Allows reporting of HLA typings that do not include DRB3/4/5

• Technology has been refined so that testing is very specific

• New parenthetical notes for these codes that provide reporting guidance

171

Molecular PathologyTier 2

• Tier 2 – Less specific and reported by level classification:

– Medically useful procedures

– Performed in lower volumes as incidence of disease being tested is rare

– Arranged by level of technical resources and interpretative work required

172

Molecular PathologyTier 2 (cont.)

• Tests added to each level indicated with arrows like a parenthetical note:IL28B9 Interleukin 28B [interferon, lambda 3]) (e.g., drug response) rs12979860 variant

• Total of 318 new analytes added to Tier 2 for 2014

173

Molecular Pathology

• If the analyte tested is not represented by a Tier 1 code and not specifically listed under a Tier 2 code, use the unlisted molecular pathology code (81479)

– 2014 CPT Changes: An Insider’s View

– Also discussed at the AMA Symposium

174

Multianalyte Assays with Algorithmic Analysis (MAAA)

• MAAAs utilize multiple results from various assays

• The assay results along with other patient information is run through an algorithm and resulted as either a numeric score or as a probability

• Unique to a single clinical laboratory or manufacturer

175


• Two new codes

– 81504 – Oncology (tissue of origin) microarray gene expression …

• Gene profiling on biopsy lesions (tissue of origin) to aid in determining diagnosis and treatment options

– 81507 – Fetal aneuploidy (trisomy 21, 18, and 13) DNA sequence analysis …

• Specifically for the Harmony Prenatal Test

• Replaces 0005M

176


• Appendix O– Appendix table lists procedures by:

• Proprietary name and clinical laboratory or manufacturer

• Alpha numeric code for each test

• Code descriptor for each test

• Updates on AMA’s website in March, June, and November:– Understands importance of reporting

these tests

177

Chemistry

• Code description updates:– Addition of “when performed” as reverse

transcription is no longer required with new testing

– Rewording to make “amplified probe technique” earlier in the definition:

• Original – Hepatitis C, reverse transcription and amplified probe technique

• Updated – Hepatitis C, amplified probe technique, includes reverse transcription when performed

178

Microbiology

• New code

– 87661 – Infectious agent detection by nucleic acid (DNA or RNA); Trichomonas vaginalis, amplified probe technique

• Added to allow reporting by new technique

179

Immunohistochemistry

• Revised description for 88342 –Immunohistochemistry orimmunocytochemistry, each separately identifiable antibody per block, cytologic preparation or hematologic smear; first separately identifiable antibody per slide

• New code 88343 – each additional separately identifiable antibody per slide (List separately in addition to code for primary procedure)

180

Immunohistochemistry

– Revision/addition to more clearly define unit of service

– Report per separately identifiable antibody per slide

181

MEDICINE SECTION2014 Updates

182

Vaccine Codes New for 2014

• New codes • 90763 – Influenza virus vaccine, trivalent, derived from

recombinant DNA (RIV3), hemagglutinin (HA) protein only, preservative and antibiotic free, for IM use:

– FLUBlok

• 90685 – Influenza virus vaccine, quadrivalent, split virus, preservative free, when administered to children 6–35 months of age, for IM use

– Fluzone

183

Vaccine Codes New for 2014

• 90686 – Influenza virus vaccine, quadrivalent, split virus, preservative free, when administered to individuals 3 years of age and older, for IM use

– Fluarix

• 90687 – Influenza virus vaccine, quadrivalent, split virus, when administered to children 6–35 months of age, for IM use

• 90688 – Influenza virus vaccine, quadrivalent, split virus, when administered to individuals 3 years of age and older, for IM use

184

Vaccine Codes

• Flu season coverage, payment, and effective dates for payment amounts:• http://www.cms.gov/Medicare/Medicare-Fee-for-

Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/VaccinesPricing.html

• Transmittal R2786CP; MM8433

185

Gastroenterology

• Revised code 91065 – Breath hydrogen or methane test (e.g., for detection of lactase deficiency, fructose intolerance, bacterial overgrowth, or oro-cecal gastrointestinal transit)– Report 91065 once for each test

administered

– Changed as 15% of the population are methane producers

186

Speech Otorhinolaryngologic Services

• Deleted code 92506 – Evaluation of speech, language, voice, communication, and/or auditory processing

• Replaced with new codes to describe the individual services with specificity:

– 92521 – Evaluation of speech fluency (e.g., stuttering, cluttering)

187

Speech Otorhinolaryngologic Services

– 92522 – Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria)

– 92523 ; with evaluation of language comprehension and expression (e.g., receptive and expressive language)

– 92524 – Behavioral and qualitative analysis of voice and resonance

188

Cardiography

• AMA Errata – Parenthetical note correction:

– For electrocardiogram, 64 leads or greater, with graphic presentation and analysis, see 0178T–0180T

– Removes reference to CPT 93799

189

Cardiac Catheterization

• Correction to parenthetical note under CPT 93463:– Removed reference to 93563, 93564

– Use 93463 in conjunction with 93451–93453, 93456–93461, 93530, 93531, 93532, 93533, 93580, 93581)

• AMA Errata

190

Repair of Structural Heart Defect

• New code 93582 – Percutaneous transcatheter closure of patent ductus arteriosus:– Most frequent method uses a ductal

occluder device or embolization coils

– Includes congenital right and left heart cath, catheter placement in the aorta and aortic arch angiography, when performed

– Includes moderate sedation

191


– Parenthetical notes include how to report in relation to other procedures:

• Other cardiac angiographic procedures performed at the time of transcatheter PDA closure

• Reporting transseptal puncture through intact septum or transapical puncture

• Repair of patent ductus arteriosus by ligation

• How to report intracardiac echocardiogram services performed at time of closure

192


• New code 93583 – Percutaneous transcatheter septal reduction therapy (e.g., alcohol septal ablation), including temporary pacemaker insertion when performed– Involves injection of absolute alcohol

which causes tissue necrosis and resolves the obstruction

– Includes insertion of temporary pacemaker when performed, and left heart cath

193


– Includes LAD coronary angiography for purpose of road mapping to guide the intervention

– Diagnostic heart cath may be reportable under usual circumstances for reporting cath with interventional procedure

– Can report with 93462 – Left heart cath by transseptal puncture (reciprocal note)

194

Electrophysiological Studies

• Revised introductory guidelines regarding ablation:– 93622 may be reported with 93653

and 93656

– 93623 may be reported with 93653–93656

– When performance of one or more components is not possible or indicated, document the reason for not performing

195


• Revised descriptions to change “when possible” to “when necessary,” include the word “bundle” with HIS, and add “and” before HIS bundle in order to have consistency in this code set

– Example – 93653 – Comprehensive EP evaluation … with right atrial pacing and recording, right ventricular pacing and recording (when necessary); and HIS bundle recording (when necessary)

196


• Revised 93656 to indicate the code may still be reported if atrial pacing and recording, right ventricular pacing and recording, and HIS bundle cannot be performed

– Added “when necessary”

197

Neurology and Neuromuscular Procedures

• Updates to instructions and parenthetical notes regarding CPT 95873 (electrical stimulation guidance) and 95874 (needle EMG guidance) in response to the changes to the chemodenervation codes

198

Intraoperative Neurophysiology

• Revised guidelines to clarify appropriate reporting of time reported:– Time spent monitoring (95940/95941)

excludes time to set up, record, and interpret the baseline studies, and to remove electrodes at the end of the procedure

– To determine the number of units of service for 95940, use the total minutes monitoring in the operating room one-on-one

199

Intraoperative Neurophysiology

– Monitoring may begin prior to incision

– 95940 and 95941 are unconditionally packaged under the OPPS (SI = N)

– Time/resources required to set up equipment, record baseline, etc., should be captured to ensure reporting of cost, but not reported based on time

– To report time spent waiting on standby for a case to start, use 99360

• For professional services only – SI (E) for OPPS

200

Drug Administration

• Updated language in guidelines to continue CPT’s “Nomenclature Reporting Neutrality” initiative

– Replaced “health care professional” with “individual”

– “an injection in which the individual who administered the drug/substance is continuously present …”

201

Active Wound Care Management

• New code 97610 – Low frequency, non-contact, non-thermal ultrasound, including topical application(s) when performed, wound assessment and instruction(s) for ongoing care, per day– Replaces category III code 0183T

– Modality utilizing acoustic or sound energy to atomize saline and deliver US energy by way of continuous mist to wound bed and surrounding tissue

202

Other Services and Procedures

• Revised description 99170:

– Anogenital examination, magnified, in childhood for suspected trauma, including image recording when performed

203

CATEGORY III CODES2014 Updates

204

Category III Codes

• Parenthetical notes cross-referencing the Category III codes are sprinkled throughout CPT book

• Many payers consider Category III codes to be experimental and non-covered

– Check with individual payers for coverage policies and reporting of study protocols

205

Subcutaneous Implantable Defibrillator System

• Ten new Category III codes:

– Implantable technology

– Complete subcutaneous system with one electrode placed under the skin

– Used for treatment of ventricular tachyarrhythmias

– No pacing capability; defib capability only

– Useful in cases of device infections and clotted subclavian veins

206


• Codes have same structure as Category I defibrillator codes:– 0319T – Insertion or replacement of the

system (generator and lead)

– 0320T – Insertion of lead only

– 0321T – Insertion of generator with existing subcutaneous lead

– 0322T – Removal of pulse generator only

– 0323T – Removal and replacement of pulse generator only

207


– 0324T – Removal of defibrillator electrode

– 0325T – Repositioning of subcutaneous electrode and/or pulse generator

• Codes include revision of skin pocket when performed intraoperatively and radiology supervision and interpretation

• To report fluoroscopic guidance for diagnostic lead evaluation without lead insertion/replacement/repositioning, use 76000

208


• 0326T – EP evaluation of subcutaneous implantable defibrillator

– Report separately during device insertion/replacement or follow-up device testing when performed

• 0327T – Interrogation device evaluation (in person) with analysis, review and report …

• 0328T – Programming device evaluation (in person) with iterative adjustment …

– Do not report 0327T or 0328T in conjunction with pulse generator and lead insertion or repositioning codes (0319T–0325T)

209

Cat III CodesPolling Question

• Why were Cat III codes created for a defibrillation system when CPT codes are available:

A. Road Runner needed a new “jump starter” to stay ahead of Wile E. Coyote

B. The lead is implanted subcutaneously

C. Revision of the skin pocket is bundled

D. The current codes don’t support the number of leads involved

210

Category III Codes Cardiology

• 0331T – Myocardial sympathetic innervation imaging, planar qualitative and quantitative assessment

• 0332T – with tomographic SPECT

• Used as a means for evaluating patients with heart failure to see if the nerve conduction is receptive to ICD insertion

211

Category III CodesExtremity Arterial Study

• 0337T – Endothelial function assessment, using peripheral vascular response to reactive hyperemia, non-invasive (e.g., brachial artery ultrasound, peripheral artery tonometry), unilateral or bilateral

– Noninvasive procedure performed on upper extremity

– Series of measurements of dilation or lack of dilation of the brachial artery or the digital arteries in response to occlusion of the vessels that “feed” these vessels in the arm

• A “control” reading may be done of the contralateral limb for reference

– Included in the procedure

212

Category III Codes0337T (cont.)

Measurement performed Location of Procedure Type of provocation

0337T Dilation of the distal arterial vessels after provocation

Upper Extremity onlyOcclusion of a desired vessel (via a cuff)

9392293923

Volume of blood in the vessel at different levels, direction of the blood flow and/or oxygen tension

Upper or Lower extremityCold stress or postural provocation

• Not a physiologic study of the upper or lower extremity arteries (defined by CPT 93922, 92923)

213

Category III CodesCardiology

• 0338T – Transcatheter renal sympathetic denervation, percutaneous approach including arterial puncture, selective catheter placement(s) renal artery(ies), fluoroscopy, contrast injection(s), intraprocedural road mapping and RSI including pressure gradient measurements, flush aortogram and diagnostic renal angiography when performed; unilateral

• 0339T ; bilateral

214

Category III Codes0338T, 0339T (cont.)

– Procedure done under study protocol

– Percutaneous renal denervation –• Performed via catheter-based approach

• Radiofrequency ablation of the nerves in the vascular wall of the arteries

• Result = decrease in the nerve activity which decreases blood pressure

– Do not report with 36251–36254• Selective and superselective catheter

placement codes (included)

215

Whew … Need a Helping Hand?

216

Polling Question

• Okay – Cast your ballots! Which of us is Wile E. Coyote or Road Runner?A. Denise is Wile E. Coyote & Joanne is

Road Runner

B. Joanne is Wile E. Coyote & Denise is Road Runner

C. They are both Wile E. Coyote

D. They are both Road Runner

E. My head hurts so badly I don’t know who I am right now

217

Submit a question:

1. Go to the Q & A box located on your screen.2. Type in your question.3. Click the Icon to send.

Questions & Answers

Denise Williams, RN, CPC-H,AHIMA-Approved

ICD-10-CM/PCS TrainerSenior Vice President

Health Revenue Assurance Associates, Inc.Plantation, Fla.

Joanne Schade-Boyce, BSDH, MS, CPC, ACS, AHIMA-Approved

ICD-10-CM/PCS TrainerDirector of Education & Curriculum

Health Revenue Assurance Associates, Inc.Plantation, Fla.

218

Thank you for attending!

Be sure to register for HCPro’s next live program:

Injections and Infusions: Identify and Overcome Top Coding Challenges

January 22, 2014 at 1:00pm Eastern

http://www.hcmarketplace.com/prod-11651

219

This concludes today’s program.

Please do not close your browser.When the presentation ends you will be automatically redirected

to the post-event survey.

Certificate of Attendance

_________________________________________________________________________________________________________________________________________________

attended

“2014 CPT Code Changes Explained”

a 120‐minute audio conference on December 10, 2013

Elizabeth Petersen Vice President, Healthcare HCPro, a division of BLR

75 Sylvan Street, Suite A‐101, Danvers, MA 01923

3871-REV-121013 - Exhibit A5 - final · 5 Presented By: Denise Williams, RN, CPC-H, is senior vice...

Documents

Transcript of 3871-REV-121013 - Exhibit A5 - final · 5 Presented By: Denise Williams, RN, CPC-H, is senior vice...