The practice of medicine constantly evolves. Established roads change direction. Familiar landmarks disappear, and new paths emerge. Even those who know the lay of the land can feel lost in an ever-shifting terrain of technologies, methods, and standards of care.

To keep your bearing, your maps must be accurate and up-to-date. For 2013, CPT® supplies a host of new directions, including more than 650 code changes, new and revised section guidelines and parenthetical instructions, and much more. Here’s a preview of what you can expect.

E/M Services

Eighty-two evaluation and management (E/M) codes in the range 99201-99467 are revised to allow a physician or other qualified health care professional to provide services. The revisions clarify that each state’s scope-of-practice laws (not CPT® descriptor language) determine the services an individual provider is qualified to perform.

For example, the revised descriptor for a level I, new outpatient visit (99201) specifies:

Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components:

• A problem focused history;
• A problem focused examination;
• Straightforward medical decision making.

Counseling and/or coordination of care with other physicians, other providers qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self-limited or minor. Physicians typically spend Typically, 10 minutes are spent face-to-face with the patient and/or family.

New (underlined) text allows that counseling and/or coordination of care may be provided with other physicians or “other qualified health care professionals,” and deleted (strikethrough) text eliminates the reference to “physician” time. Coding requirements are otherwise unchanged.

Descriptor changes throughout the E/M chapter are consistent with this example; where code descriptors are unchanged, section guidelines have been modified to allow non-physician providers (NPPs) to report services. For example, the descriptors for critical care services (99291-99292, 99468-99469, and 99471-99476) are unchanged, but section guidelines now stipulate “Critical care is the direct delivery by a physician(s) or other qualified health care professional of medical care for a critically ill or critically injured patient.”

CPT® 2013 also adds three new categories of E/M services, for a total of seven new E/M codes:

Supervision by a control physician of interfacility transport care of the critically ill or critically injured pediatric patient (99485-99486): These time-based codes report the non-face-to-face work performed by the control physician (the provider directing care) during an interfacility transport. The patient’s age, medical condition (critical illness or critical injury), and the total time must be documented.

Complex chronic care coordination services (99487-99489): These time-based services are provided to patients with complex chronic illness(es) residing at home or in a domiciliary, rest home, or assisted living facility, and typically involve implementing a care plan directed by a physician or other qualified health care professional.

Transitional care management services (99495–99496): These services, which include both face-to-face and non-face-to-face efforts, are provided to established patients “whose medical and/or psychosocial problems require moderate or high complexity medical decision making during transitions in care from an inpatient hospital setting … to the patient’s community setting.”

Each of the new categories above includes comprehensive section guidelines to help you apply the codes correctly. Look to future editions of Coding Edge for a complete breakdown.

Anesthesia

The two changes in the Anesthesia chapter are part of a recurring theme for 2013; revised descriptors no longer limit reporting to physicians. For example:

01991 Anesthesia for diagnostic or therapeutic nerve blocks and injections (when block or injection is performed by a different provider physician or other qualified health care professional); other than the prone position

Hundreds of such descriptor changes occur throughout CPT®, in nearly every chapter.

Integumentary

There is just one change in the Integumentary section this year: Code 15740 (island pedicle flap) is revised to require identification and dissection of an anatomically-named axial vessel.

Musculoskeletal

Changes in this section include revisions to allow code reporting by “other qualified health care professionals,” as well as the inclusion of conscious sedation with percutaneous vertebroplasty (+22522). New codes describe arthrodesis by pre-sacral interbody technique with instrumentation (22586), and revision of total shoulder (23473–23474) and elbow (24370–24371) arthroplasties.

You’ll find new text in the section guidelines throughout the chapter, including instructions to use modifier 76 Repeat procedure or service by same physician or other qualified health care professional when reporting “re-reduction of a fracture and/or dislocation performed by the primary physician or other qualified health care professional.”

Respiratory

New codes 31647–31651 replace Category III codes 0250T–0252T for insertion and removal of bronchial valves to treat patients with emphysema or lung damage. Similarly, new Category I codes replace Category III codes for bronchial thermoplasty.

Outdated codes have been deleted, some replaced by new codes that more accurately describe the procedures performed. For example, new codes are now available for thoracentesis (32554, 32555) and pleural drainage (32556, 32557).

Finally, there’s a new subsection and code (32701) for thoracic target delineation to identify tumor borders, tumor volume, and tumor relationship to adjacent anatomic structures. Delineation of the tumor allows the radiation oncologist to plan and deliver radiation treatments.

New codes 31647–31651 replace Category III codes 0250T–0252T for insertion and removal of bronchial valves to treat patients with emphysema or lung damage.

Cardiovascular

New codes 33361–33369 replace Category III codes 0256T–0259T for transcatheter aortic valve replacement. You will select the new codes based on whether the approach is open or percutaneous, and the vessel the surgeon uses for the approach.

Category III codes 0048T and 0050T have been deleted and replaced with 33990–33993 for insertion, removal, and repositioning of percutaneous ventricle assist devices.

New codes 36221–36228 describe selective and non-selective arterial catheter placement and angiography in the aortic arch, and carotid and vertebral arteries. They include vessel access, placement of catheter(s), contrast injection(s), fluoroscopy, radiological supervision and interpretation (S&I), and closure of the arteriotomy.

New and revised codes (e.g., 37197, transcatheter retrieval; 37211–37214, transcatheter therapy) now bundle radiological S&I services.

Digestive

Mucosal cells are evaluated using an optical endomicroscope. Several new codes have been created to support optical endomicroscopy.

Several new codes (e.g., 43206, esophagoscopy; 43252, upper gastrointestinal endoscopy) have been created to report optical endomicroscopy, which allows the provider to eliminate random sampling and perform targeted biopsies through real-time cellular observation of mucosal tissue. A new code (44705) reports preparation of fecal microbiota for instillation in a patient with clostridium difficile infection.

Urinary

Injections are made into the bladder for chemodenervation (code 52287).

In the Urinary section, you’ll now find code 52287 for chemodenervation of the bladder.

Nervous System

In this section, chemodenervation code 64614 has been revised to specify “extremity” (singular). The procedure is reported once per session when treating a single extremity, regardless of how many individual injections are made. New code 64615 describes bilateral chemodenervation of muscle(s) innervated by facial, trigeminal, cervical spinal, and accessory nerves.

Percutaneous implantation of neurostimulator electrode array to the sacral nerve (64561) now includes image guidance, when performed.

Eye and Ocular Adnexa

Codes in this section have been revised to simplify reporting of paracentesis of the anterior chamber of the eye (now reported using 65800, exclusively). Code 67810 Incisional biopsy of eyelid skin including lid margin was revised to include the depth of tissue removed, to promote proper coding. Parenthetical instructions direct you to 11100, 11101, or 11310–11313 when reporting a biopsy for the skin of the eyelid.

Radiology

Where radiological S&I is now bundled, the corresponding radiology codes have been deleted or revised.

Thrombolysis (now described with new codes 37211–37214) is performed using intra-arterial or intravenous infusion.

Codes for bronchography (e.g., 71040, 71060) have been deleted for 2013: Computed tomography (CT) is now the standard of care replacing bronchography. Codes 72040–72052 for radiology examination of the cervical spine have been revised to include the number of views to accurately capture the work performed (e.g., 72050 Radiologic examination, spine, cervical; 4 minimum or 5 views).

Where radiological S&I is now bundled, the corresponding radiology codes have been deleted or revised. For example, new codes 37211–37214 describe infusion thrombolysis with radiological S&I; therefore, 75898 Angiography through existing catheter for follow-up study for transcatheter therapy, embolization or infusion, other than for thrombolysis was revised to exclude thrombolysis.

Codes 78000–78011 have been deleted and replaced by 78012–78014 for thyroid nuclear medicine scans. New and revised codes 78070–78072 describe a greater array of parathyroid planar imaging procedures (including single-photon emission computed tomography (SPECT) and CT).

Pathology and Laboratory

The big changes here revolve around molecular pathology codes, over 100 of which were added to CPT® last year. This year we gain 13 new Tier 1 codes plus an unlisted molecular pathology procedure code (81479) with revisions to all nine Tier 2 (81400–81408) procedures. Guidelines have been added to the beginning of the codebook, with information about the history of the molecular pathology codes, instructions for use, and frequently asked questions to assist with proper code selection.

Codes 83890–83914 and 88384-88386 have been deleted and superseded by molecular pathology codes 81200–81479. All genetic testing code modifiers, previously listed in CPT® Appendix I and applied with “stacking codes” 83890-83914, also have been deleted.

A new subsection of codes (81500–81512, 81599), with guidelines, has been added to report multi-analyte assays with algorithmic analysis (MAAA), which use the results of assays (molecular pathology assays, fluorescent in situ hybridization assays, and non-nucleic acid-based assays) and other patient information, when appropriate, to calculate the patient’s probability of developing a specific condition.

Category III codes 0279T and 0280T have been deleted and replaced with Category I codes 86152–86153 to report testing for tumor cells circulating in the blood of cancer patients. A new code (86711) has been created for testing to detect the John Cunningham virus, and new codes 86828–86835 report testing for antibodies to human leukocyte antigens (HLA). New codes 87631–87633 describe nucleic acid tests performed to detect respiratory viruses, based on the number of targets for the test.

Medicine

Dozens of codes in the Medicine section have undergone descriptor revisions similar to those in the E/M chapter, which allow the reporting of services by “other, qualified non-physician practitioners.”

Revised influenza vaccine administration codes (90655–90660) now specify “trivalent” vaccine, to clarify that the vaccine includes three viral strains. There is also a new code (90672) to report quadrivalent (four viral strains) influenza vaccine for intranasal use, and 90653 Influenza vaccine, inactivated, subunit, adjuvanted, for intramuscular use is added to report the supply of adjuvanted seasonal trivalent influenza vaccine (currently awaiting FDA approval). Additional codes have been created or revised to report hepatitis B vaccines.

The psychiatry category received a major overhaul with the creation of new codes (e.g., 90832 Psychotherapy, 30 minutes with patient and/or family member and 90839 Psychotherapy for crisis; first 60 minutes) and guidelines, as well as substantial code deletions. The revised code set more accurately reports the services behavioral health providers now perform.

Codes 92980, 92981, 92982, and 92984 have been deleted and replaced by 92920–92944 for coronary therapeutic services and procedures. New guidelines define the services and provide instruction on proper code use.

Comprehensive electrophysiologic evaluation has been combined with intracardiac catheter ablation of arrhythmogenic focus services.

Nerve conductions studies (NCS) involve electronic stimulation and measurement.

Codes 95900–95904 are replaced by a more granular series of codes (95907–95913) that describe precisely the number of studies performed.

To combine comprehensive electrophysiologic evaluation with intracardiac catheter ablation of arrhythmogenic focus services, 93651 and 93652 have been deleted and four new codes (93653-93656) have been created.

Allergy testing codes 95010 and 95015 have been deleted and replaced with 95017 (venoms) and 95018 (drugs or biologicals).

In the neurology and neuromuscular procedures, polysomnography codes are now age specific (e.g., 95808, any age; 95810, age 6 years or older), and intraoperative neurophysiology monitoring code 95920 has been deleted, to be replaced by two new add-on codes: 95940 and 95941.

Lastly, nerve conduction studies are completely revamped: Codes 95900-95904 are replaced by a more granular series of codes (95907-95913) that describe precisely the number of studies performed (e.g., 95908 Nerve conduction studies; 3-4 studies). CPT® includes new subsection guidelines that specify, “For the purposes of coding, a single conduction study is defined as a sensory conduction test, a motor conduction test with or without an F wave test, or an H-reflex test.”

Modifiers and Miscellaneous

CPT® 2013 contains no new modifiers, but modifier descriptors in Appendix B have undergone extensive revisions to include “other qualified health care professional” language and specify that modifiers may be appended to non-physician services, when appropriate.

In the Category II Codes section this year you will find seven new codes, six revised codes, and one deleted code. For additional information, consult the American Medical Association’s (AMA) website at: www.ama-assn.org/ama/pub/physician-resources/solutions-
managing-your-practice/coding-billing-insurance/cpt/about-cpt/category-ii-codes.page?.

Editor’s Note: More information regarding this information is available through AAPC’s 4th quarter workshop “2013 CPT^® Coding Updates.” If you are unable to sign up for AAPC’s workshop in a nearby location, you can register for an on demand workshop via www.aapc.com.

Raemarie Jimenez, CPC, CPMA, CPC-I, CANPC, CRHC, is AAPC director of education.

G.J. Verhovshek, MA, CPC, is managing editor at AAPC.

Each year, a team of top disease experts and practice physicians work together to decide what changes will be made to the childhood immunization schedule, which helps protect U.S. children and adults from diseases. The schedule (www.cdc.gov/vaccines/recs/schedules/child-schedule.htm#printable) is evaluated based on the most recent scientific data available. Changes are announced in January and approved by the American Academy of Pediatrics (AAP), the Centers for Disease Control and Prevention (CDC), and the American Academy of Family Physicians (AAFP). Providers receive notice of the changes, and are expected to purchase and administer the immunizations to fit the new schedule.

Over the last several years new and expensive vaccines added to the schedule for adolescents, adults, and children have created a financial hardship for providers trying to balance economic pressures and best practices. A survey commissioned by the National Vaccine Advisory Committee (NVAC) reported that 62 percent of decision makers in practices delayed purchase of a vaccine some time within the past three years due to financial concerns. The survey revealed that in the prior year 16 percent of practice decision makers seriously considered stopping vaccinations for privately-insured patients due to high cost and reimbursement issues.

Offset High Costs with Appropriate Billing

How can practices continue to protect the communities they serve, prevent disease outbreak, and maintain financial viability? One way is to report the vaccines and vaccine-related services accurately, and bill appropriately. You should report vaccine administration using two families of CPT^® codes: One for the vaccine itself and one for the vaccine’s administration.

To facilitate immunization reporting, the most recent new or revised vaccine product codes, resulting from recent CPT^® Editorial Panel actions, are published on the American Medical Association (AMA) CPT^® website on July 1 and Jan. 1 in a given CPT^® cycle. These dates correspond with CPT^® Editorial Panel meetings for each CPT^® cycle (June, October, and February).

Watch for a lightning bolt symbol that was added to CPT^® in 2006 for vaccine codes pending approval from the Food and Drug Administration (FDA). A full list is in Appendix K. These are normally not reimbursed until the FDA approves the vaccine but have been assigned codes pending approval, which often happens during that CPT^® cycle.

Correct Vaccine Reporting

Use CPT^® code range 90476-90478 to report the vaccine or toxoid product only, based on the produce manufacturer and brand, the specific schedule, chemical formulation, dosage, patient’s age, and/or route of administration. The exact vaccine provided must be reported this way to meet the requirements of immunization registries, vaccine distribution programs, and other reporting systems that track usage and administration of vaccines.

With the dizzying array of vaccine producers and product names, it’s challenging to keep the CPT^® and ICD-9-CM codes straight. The AAP provides a free table with an easy-to-follow format allowing coders to access the correct CPT^® and ICD-9-CM code by knowing either the manufacturer or brand name. This resource can be found on the AAP website at http://practice.aap.org/content.aspx?aid=2334&nodeID=2002.

Be Cautious with Combination Doses

Codes are available for either individual vaccines or combination vaccines. Combination vaccines are formulations of antigens that combine multiple vaccines into a single injection (for example, 90707 Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous use). It is not appropriate to report the components of a combination vaccine when a single CPT^® code exists to report the combination.

Report Vaccine Administration Separately

CPT^® code range 90465-90474 reports the administration of the vaccine. Report these codes separately from the CPT^® code representing the vaccine product itself. These codes are reported based on the route of immunization, the patient’s age, the number of injections, and the product administered.

Each family of codes contains a code for the “first” or “one” immunization administration.

CPT^® codes 90465 Immunization administration younger than 8 years of age (includes percutaneous, intradermal, subcutaneous, or intramuscular injections) when the physician counsels the patient/family; first injection (single or combination vaccine/toxoid), per day and 90471 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid) are reported for the first vaccine administered by the injection route to a patient on a calendar date.

Codes 90467 Immunization administration younger than age 8 years (includes intranasal or oral routes of administration) when the physician counsels the patient/family; first administration (single or combination vaccine/toxoid), per day and 90473 Immunization administration by intranasal or oral route; 1 vaccine (single or combination vaccine/toxoid) are reported for the first vaccine administered by the oral or intranasal route to a patient on a calendar date.

Coding Quandary: Two Different Routes on the Same Calendar Date

Confusion arises for both payers and providers when the patient requires multiple vaccines on the same date, but administered via different methods. In this scenario, report one vaccine administration code that indicates “first,” and report the other route as an additional vaccine.

For example, a patient is receiving injectable hepatitis B vaccine and intranasal influenza vaccine. Report the vaccine administration using 90471 and +90474 Immunization administration by intranasal or oral route; each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure).

Physician Face-to-Face Vaccine Counseling

CPT^® contains pediatric-specific vaccine administration codes (90465-90468) with special requirements. To report 90465-90468, the patient must be younger than eight-years-old and the physician must perform face-to-face counseling personally. These special codes include the provider work of discussing risks and benefits of the vaccines, the cost of the nursing time to record and give the vaccine, plus the supplies associated with vaccine administration. To support these codes, the medical record must include the physician’s personal involvement in the parent/family counseling about the vaccine’s risks and benefits.

If the patient is eight years or older, and/or the physician does not personally perform the face-to-face counseling, report a CPT^® code from range 90471-90474.

In CPT^® 2009, the AMA clarified that vaccine counseling is not included in the Preventive Medicine Visits code range 99381-99397. The CPT^® book instructs coders to report immunization and vaccine risk/benefit counseling separately when performed on the same day as a preventive service.

If your practice is having trouble getting the vaccine counseling/administration codes reimbursed with other services, the Childhood Immunization Support Program (CISP) site, in cooperation with the AAP, provides information that you can share with your payers, explaining the vaccine work that is and is not included in the reimbursement for other services. Find the link at www.aap.org/immunization/
pediatricians/immunizationcongress.html.

Coding Example:

A six-month-old patient presents to your practice requiring a diphtheria, tetanus toxoids and acellular pertussis vaccine (DTaP), a Haemophilus influenzae type b (Hib), pneumococcal (PCV), and annual influenza. The parent has read a disturbing article in a magazine regarding the risks of (DTaP) vaccines, and your provider must spend time face-to-face with the parent addressing DTaP concerns, and providing additional risks/benefits discussion. The nurse provides the information sheet and additional discussion specific to the Hib, PCV, and influenza vaccines.

Coding for this service would be: 

90700 Diphtheria, tetanus toxoids, and acellular pertussis vaccine (DTaP), when administered to individuals younger than 7 years, for intramuscular use. This code is for the DTaP vaccine product.

90465 This code is for the immunization administration of the first vaccine including face-to-face counseling with the provider.

90645 Hemophilus influenza b vaccine (Hib), HbOC conjugate (4 dose schedule), for intramuscular use. This code is for the Hib vaccine product.

+90472 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure). This code is for the “additional” administration of the Hib vaccine with counseling by the nurse.

90669 Pneumococcal conjugate vaccine, 7 valent, for intramuscular use. This code is for the PCV vaccine product.

90472 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure). This code is for the additional administration of the PCV vaccine with counseling by the nurse.

90660 Influenza virus vaccine, live, for intranasal use. This code is for the intranasal influenza product.

+90474 This code is for the “additional” administration of the influenza vaccine by intranasal route.

Vaccines for Children (VFC) Program

Since its inception, the VFC Program has helped shift the nationwide vaccine delivery system away from public health and more toward private providers. VFC has accomplished this by providing free vaccines to primary care physicians, attempting to keep children in their “medical home” (their regular source of primary care), with the goal of decreasing private provider patient referrals to public health for immunizations.

Free vaccines are available to children who are under 19 years of age, and who meet any of the following criteria:

• Enrolled in the Medicaid program
• Do not have health insurance
• Have no coverage of immunization on their health plan
• Are American Indian or Alaskan Native

VFC vaccines are provided free to participating physicians, and patients/insurers can only be charged for the administration. Providers bill according to CPT^® codes based on each vaccine (type of immunization) administered. Reimbursement through Medicaid varies by state. Some state Medicaid agencies reimburse a vaccine with multiple antigens at a higher rate than a single antigen vaccine. Some states limit the amount of administration fees reimbursed per visit. Check with your state Medicaid agency to determine how the VFC administration fees should be coded and reimbursed. This program is a good way to provide important immunity while preventing reimbursement problems.

Diagnostic Coding

The diagnosis code accompanying the vaccine administration and vaccine product CPT^® code typically is specific to the disease for which the patient is being inoculated, from range V03-V06. Some payers only require the diagnosis V20.2 Routine child health exam or V20.31 Health supervision for newborn under 8 days old or V20.32 Health supervision for newborn 8 to 28 days old if the vaccines are administered as part of a complete physical on the same calendar day.

There are many reasons why an immunization may not be given, but the ICD-9-CM book has in the past only provided coders with a single code. Tracking why an immunization was not given can be as important as tracking those that are given. The AAP has requested and recently received additional codes to identify the different reasons why a patient did not receive a routine immunization. Be sure to indicate these circumstances in your practice when they apply:

V64.00 Vaccination not carried out, unspecified reason

V64.01 Vaccination not carried out because of acute illness

V64.02 Vaccination not carried out because of chronic illness or condition

V64.03 Vaccination not carried out because of immune compromised state

V64.04 Vaccination not carried out because of allergy to vaccine or component

V64.05 Vaccination not carried out because of caregiver refusal

V64.06 Vaccination not carried out because of patient refusal

V64.07 Vaccination not carried out because for religious reasons

V64.08 Vaccination not carried out because patient had disease being vaccinated against

V64.09 Vaccination not carried out because of other reason

The nation’s providers are soldiers in the campaign to vaccinate America’s citizens, but the soaring cost and rising number of new vaccines make it difficult for them to buy the shots that are often under-reimbursed. With correct coding and accurate billing of all services rendered, coders can be an important part of keeping their patients healthy.