Vol. 13 •Issue 17 • Page 6
Know the Latest & Greatest CPT Code Changes
To be prepared for the upcoming CCS and CCS-P exams, coders should be particularly aware of the latest CPT and ICD-9-CM revisions, additions and deletions. This column will focus on those CPT codes that were revised or added as of January 2003. By being conscious of these coding changes, exam applicants can ensure that they’re ready for the test. Many examination questions are pulled from the latest coding updates to ensure that coders don’t use memorized codes and that they’re doing the necessary ongoing education required of coding professionals.
There were a large number of changes to CPT for 2003, but the majority that will affect hospital and physician coders reside in the surgical section of the manual. These are highlighted below:
•Fine needle aspiration procedures: Many coders remain confused when differentiating fine needle aspirations from fine needle core biopsies. CPT 2003 includes a parenthetical note that references the specific codes for the tissue core biopsies so that those services aren’t included in the needle aspiration codes (10021 and 10022).
•Excision of benign and malignant skin lesions: Due to confusion concerning “re-excision” of lesions and the appropriate designation of the size of lesions excised, the entire range of lesion excisions (11400 – 11446 and 11600 – 11646) has been revised. The codes now include the margins that are excised around the lesion itself. The physician performing the excision should document the size of the lesion and the size of the margins required to completely excise the lesion.
•Trigger point injections: The code series 20550 – 20553 has been revised to indicate that the codes are to be reported only one time per session, regardless of the number of injections or muscles injected. In the past, the code was reported for each injection, a cumbersome endeavor when some physicians provide 10 or more injections at one visit. The code terminology now includes “one or two muscles” or “three or more muscles.”
•Lower extremity strapping: Code 29540 (previously strapping of the ankle) has been revised to now include strapping of either the ankle or the foot. The treatments related to these two anatomical sites are often similar in nature, and so both are contained within the same CPT code.
•Repositioning of previously implanted pacemaker or defibrillator electrodes: Prior to 2003, there was no CPT code to describe a visit to the cardiac catheterization lab solely for electrode repositioning during the first 14 days post initial or reinsertion. The new codes (33215 and 33226) are to be assigned when the electrode is repositioned but not replaced, regardless of the time frame following the initial placement or reinsertion procedure.
•Mechanical removal of pericatheter or intracatheter obstructive material from a central venous device: There are two new codes for 2003 (36536 and 36537) to describe the mechanical removal of thrombus material that very commonly obstructs venous access devices that are typically used for chemotherapy, dialysis, etc. Fibrin or thrombus may collect in either the distal end of the device or within the device itself, requiring removal. Mechanical removal prevents the need for removal and insertion of a new device. These codes should be used for treatment of the tunneled catheter devices, which are commonly provided for use for both hemodialysis and chemotherapy patients.
•Esophagoscopy, EGD, sigmoidoscopy and colonoscopy with directed submucosal injection(s): Prior to CPT 2003, there were no CPT codes to describe the additional time and work required for patients undergoing GI endoscopy services with submucosal injection(s). The code descriptor indicates “any substance” and should be reported only once for each procedure regardless of the number of injections performed. The new codes are 43201, 43236, 45335 and 45381.
•Bladder catheter introduction: There are three new CPT codes for 2003 that describe introduction of a catheter into the bladder. Code 51701 describes insertion of a non-indwelling catheter, which is most commonly inserted to obtain residual urine. Code 51702 describes simple placement of an indwelling bladder catheter, such as a Foley catheter, most often inserted to treat urinary retention or neurogenic bladder. Code 51703 also describes indwelling catheter insertion, but this insertion involves a complication, such as altered anatomy or a fractured catheter or balloon. It is extremely important for the coder to recognize that these codes should only be assigned when performed independently and not as a component of other procedures.
•Laparoscopic radical retropubic prostatectomy: Advances in medical technology allow more procedures each year to be migrated to a laparoscopic approach. New for CPT 2003, the radical retropubic prostatectomy can now be safely performed without an open incision and is a less invasive alternative. Code 55866 should be assigned for this procedure, which includes nerve sparing.
•Colposcopy of the vulva (56820 – 56821), entire vagina (57420 – 57421) and cervix (57452 – 57461): Prior to 2003, there were only three colposcopy codes available for assignment, and these were located in the vagina section of CPT, even though the majority of the services performed were based primarily on the cervix. The vulva endoscopy codes are limited to the vulva only. Additional endoscopic examinations of other sites should be reported separately. If the focus of the examination is the entire vagina, codes 57420 or 57421 should be reported, including circumstances when the cervix is viewed adjunctively. If, however, the cervix is the focus of the examination, then the endoscopy codes in the Cervix Uteri section should be reported instead. The CPT 2003 revisions in this section also serve to further delineate between codes 57460 (Colposcopy of the cervix with loop electrode biopsy(s) of the cervix) and 57461 (Colposcopy of the cervix with loop electrode conization of the cervix). Loop electrode biopsy (57460) typically does not include removal of a portion of the endocervix or the transformation zone (the area at risk for cervical cancer) and so is not considered a conization procedure.
•Myomectomy, vaginal hysterectomy and laparoscopic vaginal hysterectomy: The code range that reflects codes for myomectomy, vaginal hysterectomy and laparoscopic vaginal hysterectomy now includes terminology that differentiates between the size (weight) of the uterus by excisional methods (58290 – 58294) and laparoscopic methods (58550 – 58554). Prior to 2003, there was no distinction between the standard and the more complex vaginal hysterectomy procedures.
•Nerve block procedures: The range of codes that describes nerve blocks (injection of an anesthetic agent into the somatic nerves) was revised to differentiate between a single injection and a continuous administration via catheter infusion. The series includes codes 64400 – 64448. These codes should not be reported in addition to a code from the anesthesia section of the CPT manual.
•Use of ophthalmic endoscope: Code 66990 has been added to CPT as an “add-on” code to describe the use of an ophthalmic endoscope only when performed in conjunction with the following procedures:
•Severing adhesions of anterior segment of eye, incisional technique (with or without injection of air or liquid); posterior synechiae (65875),
•Removal of implanted material, anterior segment of eye (65920),
•Insertion of intraocular lens prosthesis (secondary implant), not associated with concurrent cataract removal (66985),
•Exchange of intraocular lens (66986),
•Vitrectomy, mechanical, pars plana approach; with epiretinal membrane stripping (67038),
•Vitrectomy, mechanical, pars plana approach; with focal endolaser photocoagulation (67039),
•Vitrectomy, mechanical, pars plana approach; with endolaser panretinal photocoagulation (67040).
The endoscope offers a more extended view of the eye anatomy that is currently not accessible through the operating microscope.
•Ventilating tube removal under general anesthesia: A new code (69424) was added to describe the removal under general anesthesia of a tympanostomy tube that has failed or that is causing problems (e.g., local infection, cholesteatoma formation, or granulation). This code should be reported regardless of whether the tube was placed by the same surgeon or another surgeon and is considered a unilateral procedure. If performed bilaterally, modifier 50 should be appended to the code.
•Refilling and maintenance of implantable pump or reservoir for drug delivery, spinal (intrathecal, epidural) or brain (intraventricular): Code 95990 was added to report refilling and maintenance of implanted pumps or reservoirs for spinal and brain drug delivery systems. The refill and maintenance of the different pumps are very different in terms of risks, knowledge and skill required, and severity of potential complications from that of pumps residing in other areas of the body.
•Laser treatment for inflammatory skin disease (psoriasis): A new series of codes (96920, 96921 and 96922) for the treatment of psoriasis was added to the Medicine section of CPT for 2003. It differs from the existing 17000 series of codes in the Integumentary section that reflects laser destruction services. Those codes in the Integumentary section are to be reported for the treatment of skin lesions as opposed to the new codes that are intended to report laser treatment of inflammatory skin diseases. The three new codes are differentiated by the total area treated in square centimeters.
After review of the above scenarios and Appendix B of the CPT manual (Summary of Additions, Deletions, and Revisions), test your knowledge with the quiz below:
1. A 66-year-old man with a history of lung cancer that had been previously treated with radiation therapy has been identified to have a radiation-induced benign stricture of his mid-thoracic esophagus. The patient was taken to the endoscopy suite, and a video endoscope is advanced via the mouth into the esophagus to the level of the stricture. The degree of stenosis precludes passage of the scope beyond the strictured segment. A through-the-scope balloon dilator is passed through the endoscope and positioned across the stricture, which is then dilated to 12 mm. After satisfactory dilation, the balloon dilator is then withdrawn. With the intent of preventing repeat stricture formation at the site of the previous scarring, a sclerotherapy needle is passed through the endoscope and positioned at the level of the esophageal stricture. With careful manipulation of the needle tip, the endoscope injects steroid solution into the strictured segment in a four-quadrant method. When stable, the endoscope is withdrawn.
The appropriate CPT codes for the coding scenario above are:
a. 43249, 43236
b. 43201, 43220
c. 43456, 43201
d. 43204, 43236
2. True or false: CPT code 51702 or 51703 should be reported whenever an indwelling Foley catheter is placed.
3. True or false: If a physician documents that an “FNA of the lung” was performed, but the pathology report indicates that tissue was removed for biopsy, an FNA code (10021 or 10022) should be reported.
4. A 72-year-old woman with gastric cancer and a subcutaneous port presents with a poorly functioning port. Infusion and injections can be made, but blood cannot be aspirated. A vascular snare is placed in the vein through the catheter, and the tip of the central venous catheter is engaged with the snare. The fibrin sheath and thrombus are stripped from the catheter.
The appropriate CPT codes for the coding scenario above are:
5. A 45-year-old woman has a Pap smear that shows a high-grade squamous intraepithelial lesion. Three years ago she had a radical hysterectomy for Stage 1B squamous cell carcinoma of the cervix. Acetic acid is applied to the entire vagina, which is then evaluated with the colposcope at several magnifications. A suspicious lesion is noted at the vaginal cuff and a second area in the mid-vagina. Both areas are injected with local anesthetic; biopsies are taken; and bleeding is controlled with silver nitrate.
The appropriate CPT codes for the coding scenario above are:
This month’s column has been prepared by Cheryl D’Amato, RHIT, CCS, director of HIM, and Melinda Stegman, MBA, CCS, manager of clinical HIM services, HSS Inc. (www.hssweb.com), which specializes in the development and use of software and e-commerce solutions for managing coding, reimbursement, compliance and denial management in the health care marketplace.
Coding Clinic is published quarterly by the American Hospital Association.
CPT is a registered trademark of the American Medical Association.
1. b: The procedure was an esophagoscopy only, and the balloon dilation was performed through the scope. Codes 43201 and 43220 are appropriate.
2. False: A CPT code for placement of an indwelling Foley catheter should only be reported when it is the only service provided. It should not be assigned when the catheter placement is performed in association with another procedure.
3. False: If tissue was obtained, the procedure was a percutaneous needle core biopsy, not a fine needle aspiration procedure. CPT code 32405 should be reported instead of one of the FNA codes.
4. c: The appropriate code is 36536 be-cause the obstruction was removed from the central venous device itself. The device was not specified as an AV fistula, and no balloon device was utilized.
5. c: The appropriate code is 57421 be-cause the biopsies were performed on the vagina via a colposcopic approach.