By Melody S. Irvine, CPC, CPMA, CEMC, CFPC, CPC-I, CCS-P, CMRS
As a physician auditor, I spend much of my time educating clinicians on proper documentation. This involves explaining and interpreting coding and compliance guidelines. When providing such guidance, the most common reply I hear from providers is, “I want it in writing.” An auditing compliance plan helps to satisfy this need.
Formulate a Plan
An auditing compliance plan gives providers written details of what is expected and/or permitted for documentation and billing purposes. For example, a plan may specify what terminology is permissible, which examination guidelines will be used, and the documentation required to support a type or level of service.
An effective plan also provides a map for all auditors (internal or external) to follow, and shows a practice’s “due diligence” in monitoring, education, and documentation. Finally, per the Office of Inspector General (OIG), auditing and monitoring of physician documentation is required.
Get It in Writing
The accompanying sample auditing compliance plan (pages 48-51) can aid in developing an effective plan of your own. Use this as a guide only; your auditing compliance plan should be based on your medical practice, Medicare/payer guidelines, and the recommendations of your compliance officer. I also recommended your practice’s health care attorney to review any compliance plan you put in place.
Put Your Plan into Motion
Formulating your auditing compliance plan is step one. You must also put the compliance plan into effect and ensure that it’s followed.
Auditing Compliance Plan Sample
A. Purpose of Audits
(Name of Medical Practice) promotes adherence to an Auditing Compliance Program as a major element in the performance evaluation of all Providers/Non-physician Practitioners (NPPs) documentation. Providers are bound to comply, in all official acts and duties, with all applicable laws, rules, regulations, standards of conduct, including, but not limited to laws, rules, regulations, and directives of the federal government and the state of ______________, Medicare Contractor, Fiscal Intermediary (FI), or Carrier (Name of MAC Provider) and rules policies and procedures of (Name of Medical Practice).
B. Orientation and Training
All new Physicians/NPPs will receive orientation and training in documentation and auditing policies and procedures. Failure to participate in required training may result in disciplinary actions, up to and including, termination of employment. Every Physician/NPP is asked to sign a statement certifying they have received, read, and understood the contents of the auditing compliance plan.
Every Physician/NPP will receive periodic training updates in auditing. Ongoing education will be based on regulatory changes. Attendance is mandatory for all providers.
Auditors will conduct ongoing evaluations of compliance auditing processes involving thorough monitoring. The audits will inquire into compliance with specific rules, policies, documentation and policies of Medicare FIs or Carriers. Audits should identify any patterns and trends, non-compliance, or violations.
All audits will be performed by Certified Coders with one or more of the following credentials; (CPC®, CPMA®, etc.). Auditors will be audited by external resources to monitor their accuracy and performance.
Frequency of Audits
Internal audits will consist of a minimum of 10 audits per Provider and will be conducted on a (monthly/quarterly/semi-annual/annual) basis. They will be selected on (random basis, trending reports, frequency).
Audit Error Rate
Error rates will be conducted with Provider audits and required to pass audits at a minimum of (90 percent is recommended).
Following each audit, Physicians will receive a written report, including:
- Patient name/date of service
- Provider name
- Level billed/level documentation supports
- Diagnosis codes billed/diagnosis documentation supports
- Any coding/billing discrepancies
- Medical necessity
- Auditor name
E. Non-compliant Physicians/NPPs/Auditors
When disciplinary action is warranted, it should be prompt and imposed according to written standards of disciplinary action. Continuous violations will be reported and the Medical Director will determine the appropriate actions.
F. Documentation Requirements
New vs. Established Patients
Documentation should clearly state when the patient is new to the practice. A new patient is one that has not been seen within the same group practice in three years.
These three components will be used to qualify the level of service performed. If any of the components is missing from the documentation, the services will not be billed.
- Medical decision making
Counseling/Coordination of Care/Time
- Documentation requirements:
- Time spent counseling, detailed documentation of counseling
- Coordination of care – documentation of time, detailed documentation of coordination of care provided, and conversations with other health care providers
The medical record should clearly reflect the chief complaint. The chief complaint will support the medical necessity of the services/procedures provided.
Three chronic illnesses can be used for an extended history of present illness (HPI).
HPI can be recorded by the ancillary staff or by the patient, but must be reviewed and confirmed by the provider.
Review of systems (ROS) and past medical, family, social history does not need to be re-recorded if obtained during an earlier encounter; however, documentation of no change, and that the information was reviewed, must be noted.
Documentation should clearly reflect the patient condition or circumstances that prevented the provider from obtaining any history.
Documentation of unremarkable and non-contributory are not acceptable forms of documentation.
Documentation of normal or negative is permissible, but abnormal findings must be described.
ROS must meet medical necessity of the systems reviewed.
“All others negative” (is or is not) acceptable with (your FI name).
If an element is used in the HPI, it cannot be used in the ROS.
All audits are based on 1995 or 1997 Documentation Guidelines for Evaluation and Management Services.
The extent of examination performed must meet medical necessity for the patient’s illness, condition, or injury.
Abnormal or any relevant negative findings should be documented and described. Negative, normal, unremarkable, and/or noncontributory are not acceptable forms of documentation.
Certain acronyms are not permissible. Each organ system or body area should be described in detail.
The level of examination for 1995 guidelines will be determined as:
- 1 body area or 1 body system – Problem Focused
- 2-4 body areas and/or body systems – Expanded Problem Focused
- 5-7 body areas and/or body systems – Detailed
- 8 or more body systems – Comprehensive
Medical Decision Making (MDM)
No credit is given for a diagnosis that is not applicable to that day’s visit, unless it is a secondary issue.
Diagnoses must have relevance to the treatments provided or ordered.
Attending Physician should document when interpretation was done, and the results.
If history is obtained from someone other than the patient, this information must be documented.
When old records are reviewed, document that fact, along with a summary of those records.
Discussions with other health care providers must be documented, with a summary of the conversation.
Diagnosis codes for billing services, and ordering ancillary services, must be supported in the medical record.
Include information that will be important for ICD-10.
G. Other Evaluation and Management (E/M) Coding Guidelines
Critical Care (99291-99292)
Critical care must be supported by documentation. Time spent with the patient in critical care must be documented in the medical record. If the patient is unable to participate in discussions, time spent with family members or another decision maker must be documented.
Consultation Visits (non-Medicare Patients)
Consultations must be documented as a request for an opinion from another provider. It is the Provider’s responsibility to make sure a report is written to the referring Provider. The report must be documented. The documentation must state the reason for the consultation, as well as the Provider’s opinion and recommendation.
Observation Care Codes (8-hour Rules)
Observation services that are less than 8 hours and performed on the same calendar day: Report 99218-99220 without discharge code 99217.
Observation care performed at a minimum of 8 hours, but less than 24 hours, on same calendar day: Report 99234-99236 without 99217.
Patients admitted to inpatient for less than 8 hours: Report 99221-99223 without discharge codes 99238-99239.
Prolonged Services (99354–99357)
Codes 99254-99357 must be used with other E/M codes.
Time spent with the patient must be face-to-face and documented in the medical record.
Each additional 30 minutes (minimum of 15 minutes) must be documented.
Documentation must support billed prolonged services.
Prolonged services without face-to-face services (99358-99359) are not billable.
Care Plan Oversight
Care plan oversight can be billed for patients in office/outpatient, hospital, home, nursing facility, hospice, home health agency, or domiciliary settings for non-face-to-face services.
Only one Physician can report care plan oversight per month.
Documentation must detail:
i. Patient name, date of service
ii. Detail of services performed
iii. Time spent on non-face-to-face services
iv. Physician name
Preventive Medicine (99381-99397)
Office E/M (can or cannot) be charged during a preventive visit for any abnormality that is encountered.
A separate note for the abnormality must be documented to support the visit.
Any insignificant problem or abnormality is included in preventive care.
H. Procedure/Surgery Documentation
Procedures performed without an E/M component must be documented in detail with:
Date of surgery, patient name and date of birth, surgeons, anesthesiologist and type of anesthesia used, facility where services were performed, consents obtained, preoperative diagnosis/postoperative diagnosis, indications for the procedure, IV infusions, description and details of procedure, findings, complications and how they were resolved, diagnostic reports/pathology reports, intra-operative information, postoperative condition of patient, and signatures.
I. Cloning Documentation
Cloning is “cut-and-paste” documentation resulting in the medical record being worded exactly the same or similarly to previous entries or encounters. Cloning is not acceptable.
J. Medical Necessity
Auditors will take reasonable measures to ensure that claims for services for office encounters and all procedures performed are reasonable and necessary, given the patient’s condition. All documentation must meet the medical necessity and MDM of the level charged.
K. Addendums/Late Entries
Any corrections to the medical record, such as addendums or late entries, are acceptable within (days/weeks/months). Dates of addendums/late entries must be documented.
Below are the only acceptable acronyms used for (Name of Medical Practice):
1. HTN – Hypertension
2. COPD – Chronic Obstructive Pulmonary Disease
1. HEENT in examination)
M. Handwritten Notes
Handwritten notes (i.e., hospital encounters that are handwritten) will be reviewed by two separate auditors, if illegible. If either auditor is unable to decipher handwritten information, the documentation will be considered non-billable.
Modifier use will be audited according to frequency and proper use.
O. Advanced Beneficiary Notice
of Noncoverage (ABN)
ABNs must be presented to the patient before a service/procedure is performed to notify the patient that Medicare may not cover the service. The entire form must be completed and signed by patients, but only for those services that may not be paid by Medicare.
P. Unbundling of Services
Some services are bundled into services per National Correct Coding Initiative (NCCI) edits. These services will not be unbundled per the request of a Provider unless documentation or modifiers support the medical necessity. Some items—such as pulse oximetry and electrocardiograms—are routinely bundled into office visits and not billed separately.
Q. Global Days/Surgical Packages
Services included in global days and surgical packages cannot bill be separately.
NPP professional services can be billed as incident-to with the following guidelines.
New patients are not billed as incident-to.
Established patients with new problems are not billed as incident-to.
The Supervising Physicians must be present in the office and immediately available when billing incident-to.
The record must be clear that the Physician has performed all components of the service. Documentation should include that the information was obtained by the scribe acting on behalf of the Physician, the scribe’s name, and the date. Documentation should include a statement that the information obtained by the scribe has been reviewed and verified by the Physician.
All signatures should be original or electronic and legible. Stamped signatures are not allowed. Attestation statements may be required if signature requirements are not met.
U. Teaching Physician Guidelines
Provided office services will be determined by the combine documentation from the Resident and Teaching Physician. The Resident can document his or her services in the office and the Teaching Physician must also document his or her participation of the service rendered. If documentation is incomplete or invalid, the Teaching Physician must document as if services were performed in a non-teaching setting.
Most practices have a medical director or a physician who is a “cheerleader” and supports coders, auditors, and compliance standards. This is the person you want to have help you develop and implement your plan. If you have a physician’s support, you have won half the battle. Organize an auditing compliance committee to develop the plan, and meet regularly for follow-up, amendments, and disciplinary measures with non-compliant individuals. You cannot expect your physicians to follow all rules and regulations without proper training.
Melody S. Irvine, CPC, CPMA, CEMC, CFPC, CPC-I, CCS-P, CMRS, is owner of Career Coders, LLC, a medical billing and coding school in Colorado. She served as an officer on the AAPC National Advisory Board.
April 1st, 2013
Successfully apply E/M code modifications in several service categories.
With the release of CPT® 2012, evaluation and management (E/M) guidelines have been updated to clarify the meaning of “new” vs. “established” patients, and code use has been modified for several service categories. Here’s what you need to know to apply these changes successfully.
Three-year Rule Applies to Same Group, Same Subspecialty
Clarifying the definition of new vs. established patients, CPT® now states, “A new patient is one who has not received any professional services from the physician or another physician of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.” This is a restatement of the familiar “three-year rule,” but is significant in allowing a physician to bill a new patient service (e.g., 99202–99205), even if another physician in the group practice has seen the patient within the past three years—as long as the physicians are of a different specialty/subspecialty.
To make the new/established determination easier, CPT® 2012 Professional Edition reintroduces the “Decision Tree for New vs. Established Patients” to the E/M Services Guidelines.
The E/M Services Guidelines further clarify, “Solely for the purposes of distinguishing between new and established patients, professional services are those face-to-face services rendered by a physician and reported by a specific CPT® code(s).” A patient might still be new, for instance, if the physician had interpreted test results a month earlier, but had provided no face-to-face services within the previous three years.
Initial Observation Care Can Be Time-based
Many E/M service codes include a reference time: For instance, the descriptor for established outpatient visit code 99214 specifies, “Physicians typically spend 25 minutes face-to-face with the patient and/or family.” The reference time allows you to report a service based on time (rather than the key components of history, exam, and medical decision-making (MDM)) when “counseling and/or coordination of care dominates (more than 50 percent) of the physician/patient and/or family encounter,” per CPT® instructions.
As an example, the physician spends 30 minutes with an established patient who has been newly diagnosed with type 2 diabetes. During the entire visit, the physician discusses lifestyle changes to help manage the disease and answers questions from the patient and the patient’s wife. Based on the key components of history, exam, and MDM, the visit might not support even the lowest-level service. If the physician documents his counseling and the nature of the discussion, however, a level IV visit (99214) could be supported based on time alone.
For 2012, reference times have been added to initial observation care codes, which did not previously include them (See table below for new language in code descriptor).
2012 Added Code Verbiage
New Language Added to End of Code Descriptor
||Physicians typically spend 30 minutes at the bedside and on the patient’s hospital floor or unit
||Physicians typically spend 50 minutes at the bedside and on the patient’s hospital floor or unit
||Physicians typically spend 70 minutes at the bedside and on the patient’s hospital floor or unit
Time attributed to the service must be face-to-face with the patient and/or decision makers, or may include unit/floor time in the hospital or nursing facility. Adding reference times to these codes also allows for the use of prolonged services in addition to the initial observation care.
Prolonged Services Get an Overhaul
CPT® 2012 adds significant new text directing proper use of prolonged services codes 99354–99357. It defines direct patient contact as “face-to-face,” but also counts “additional non face-to-face services on the patient’s floor or unit of the hospital or nursing facility during the same session.” All codes report the total time duration of care (time does not have to be contiguous), and are in addition to other E/M services that include reference times. A complete list of such services—now including initial observation care services 99218–99220—may be found following the code descriptors.
The term “face-to-face” has been stricken from the code descriptors to allow unit/floor time to count in the inpatient setting; and the codes no longer apply specifically to physicians, but to physicians and “other qualified health care professionals” (deleted text has been struck through).
+99354 Prolonged physician service in the office or other outpatient setting requiring direct patient (face to face) contact beyond the usual service; first hour (List separately in addition to code for office or other outpatient evaluation and management service)
+99355 each additional 30 minutes (List separately in addition to code for prolonged physician service)
+99356 Prolonged physician service in the inpatient or observation setting, requiring unit/floor time beyond the usual service; first hour (List separately in addition to code for inpatient evaluation and management service)
+99357 each additional 30 minutes (List separately in addition to code for prolonged physician service)
Either 99354 or 99356 (depending on the setting) is used to report the first 30-74 minutes of prolonged care (above and beyond the reference time for the primary E/M service). Report only a single unit of 99354 or 99356 per date of service. Codes 99355 and 99357 may be used to report each additional 15-30 minutes of prolonged service beyond the first hour. You may not separately report prolonged services of fewer than 30 minutes.
For example, the physician provides a two-hour counseling/coordination of care session with an established patient just diagnosed with a chronic, but controllable illness. The reference time for the highest-level established outpatient code (99215) is 40 minutes. The physician has provided 80 minutes of service beyond the reference time. If supported by documentation, the physician would report 99215 for the first 40 minutes, 99354 for the next hour, and 99355 for the remaining 20 minutes.
Codes for prolonged services without direct patient contact (99358–99359) have undergone similar revisions; for instance, the codes now apply to physicians and other qualified health care professionals (not just physicians). These codes specifically apply to extensive record review or other time not spent face-to-face with the patient/caregiver or unit/floor time in the hospital or nursing facility. The services need not be provided on the same day as the primary service, and the primary service does not have to include a reference time.
More Services Are Included in Neonatal/Pediatric Critical Care
Lastly, CPT® includes some new language in the guidelines directing use of inpatient neonatal and pediatric critical care (99468–99472) intensive services (99475–99476) codes, and for initial and continuing intensive care services (99477).
Many services/procedures are bundled to critical care, including vascular access and lumbar puncture, to name a few. This year, car seat evaluation (as reported with new codes 94780–94781) has been added to the list of bundled procedures.
Physicians may separately report any services not specifically enumerated by CPT® as included in 99468–99472 and 99475–99476; facilities, however, may separately report even the included services.
New instructions have also been added to clarify billing when a critically ill neonate or pediatric patient is transferred to lower-level care. CPT® specifies “the transferring physician does not report a per day critic care service.” Instead, either 99231–99233 (subsequent hospital care) or 99291–99293 (critical care) is reported. The receiving physician reports “subsequent intensive care (99478–99480) or subsequent hospital care (99231–99233), as appropriate based upon the condition of the neonate or child.”
Similarly, when a neonate is transferred from intensive care (99477) to a lower-level care, the transferring physician should report subsequent hospital care (99231–99233). If the neonate or infant must be transferred to critical care on a day when initial or subsequent intensive care services have been performed, the transferring physician may report either the critical care (99291-99292) or the intensive care (99477), but not both. The receiving physician may report subsequent inpatient neonatal or pediatric critical care (99469 or 99472).
G.J. Verhovshek, MA, CPC, is managing editor at AAPC.
January 1st, 2012
Whether it’s new modifiers, E/M, radiology, or Category II codes, we have the outlook for what’s on the horizon.
By Raemarie Jimenez, CPC, CPMA, CPC-I, CANPC, CRHC
CPT® 2012 arrives with over 500 code changes, plus minor additions to the Evaluation and Management Services Guidelines.
The revised evaluation and management (E/M) guidelines clarify the “three-year rule” for new versus established patients, stressing “A new patient … has not received any professional services from the physician or another physician of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years” [emphasis added]. In this context, CPT® 2012 defines “professional services” to mean any face-to-face service “rendered by a physician and reported by a specific CPT® code(s).”
To help determine a patient’s status easily, CPT 2012® re-establishes the “Decision Tree for New vs. Established Patient” that was included in CPT® 2010, but left out in 2011.
The “Instructions for Use of the CPT Codebook” are unchanged, as are the Anesthesia, Surgery, and Medicine sections guidelines. Appendix A adds two modifiers not found on the inside front cover of the book, however.
Modifier 33 Preventive services has been effective since Jan. 1, 2011, but appears in CPT® for the first time. Append this modifier when reporting preventive services delivered “in accordance with a US Preventive Services Task Force A or B rating in effect” and “other preventive services identified in [legislative or regulatory] preventive services mandates.” Examples include the Medicare initial preventive physical exam (G0402) and annual wellness visits (G0438 and G0439).
Do not apply modifier 33 for separately reported services specifically identified as preventive (such as screening mammography, 77057; screening colonoscopy, G0105 or G0121; or prostate screening with PSA, G0103). If the physician converts a screening colonoscopy to a diagnostic colonoscopy (e.g., 45385), you should instead append modifier PT Colorectal screening test converted to diagnostic test or other procedure to the diagnostic colonoscopy code to indicate the procedure began as a preventive service.
Append modifier 92 Alternative laboratory platform testing when:
- A laboratory test is performed using a kit or transportable instrument that wholly or in part consists of a single use, disposable, analytical chamber;
- the test does not require permanent dedicated space; and,
- the test is designed to be carried or transported to the vicinity of the patient for immediate testing at that site.
For Medicare payers, modifier 92 indicates point-of-service HIV testing (86701-86703 and 87389) only. Per Centers for Medicare & Medicaid Services (CMS) transmittal 2277, modifier 92 is effective Oct. 1, 2011 for this purpose. Modifier 92 was introduced in CPT® 2008, and Medicare will allow you to apply the modifier retroactively to claims filed on or since Jan. 1, 2008.
CPT® 2012 re-establishes the “Decision Tree for New vs. Established Patient” that was included in CPT® 2010, but left out in 2011.
Category I Changes
The majority of changes to CPT 2012® involve Category I codes, to include over 200 new codes, more than 180 deleted codes, and more than 130 revisions. Only the Anesthesia (00100-01999) and Surgery: Urinary System (50010-53899) portions of CPT® were untouched this year.
Evaluation and Management
E/M changes include the addition of “reference times” to Initial Observation Care codes 99218, 99219, and 99220. For example, the descriptor for 99220 now specifies, “Physicians typically spend 70 minutes at the bedside and on the patient’s hospital floor or unit.” The new language allows physicians to report the initial observation care codes using time as the key component, when counseling or coordination of care dominates the encounter.
Prolonged Services codes 99354-99355 (office or outpatient) and 99356-99357 (inpatient or observation) gain instructions stating these codes may be used by physicians or other qualified health care professionals. These add-on services specifically include total face-to-face time with the patient, as well as non face-to-face services on the patient’s floor or hospital/nursing facility unit during the same session. The time does not have to be continuous, but only a single prolonged service code may be reported per day.
Prolonged services without direct patient contact (99358-99359) also gain guidelines, clarifying that these add-on services may be provided on a different date than the related, primary service (which must have been face-to-face, but need not have a reference time).
Added guidelines now precede the Inpatient Neonatal and Pediatric Critical Care (99468-99476) and Initial and Continuing Intensive Care Services (99477-99480) codes to define more precisely the services included and how the codes are applied.
The big news in the Integumentary section is a near complete overhaul of the skin replacement/skin substitute codes. Many codes in the 15300-15431 range have been deleted, replaced by fewer (and much simplified) codes, such as 15271 Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area and +15272 … each additional 25 sq cm wound surface area, or part thereof (List separately in addition to code for primary procedure). The replacement codes (15271-+15278) do not include supply of the graft, which may be reported separately.
Add-on code 15777 Implantation of biologic implant (eg, acellular dermal matrix) for soft tissue reinforcement (eg, breast, trunk) (List separately in addition to code for primary procedure) has been established to describe biologic implant for soft tissue reinforcement. Many other integumentary code descriptors include minor revisions.
Changes to musculoskeletal codes involve mainly descriptor revisions, either to clarify the intent of the service or to describe bundled services. For example, descriptors for percutaneous vertebroplasty (22520-22522) specifically identify bone biopsy as an included service when performed. A number of injection procedures (e.g., 27096 Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed)) now clearly include image guidance.
Two new codes (22633 and 22634) describe arthrodesis via combined posterior and posterolateral technique with posterior interbody technique.
Codes describing thoracotomy and other procedures of the lung and pleura undergo significant changes, to include nearly a full page of new instructions and added parenthetical notes. Every “removal of lung” code (32440-32491) has been revised. There are six new codes for thoracotomy (32096-32098, with biopsy; and 32505-+32507, with wedge resection), and an entirely new category (32601-32674) has been established for video-assisted thoracic surgery (VATS), which includes a dozen new codes.
Pacemaker or Pacing Cardioverter-Defibrillator codes (33202-33249) have undergone frequent revisions in the past few years, and 2012 is no exception. There’s an additional page of instructions for code application, as well as a quick reference chart to help with code selection for the insertion, removal, etc. of a pulse generator and its various components. Over a dozen codes in this section have been revised, with nine codes added.
Combination codes were added to report renal catheterization and angiography (36251-36254). The new codes include the radiological supervision and interpretation.
Added instructions clarify that replacement of ventricular assist device pump (33981-33983) includes removal of the new pump, as well as connection, de-airing, and initiation of the new pump.
There are relatively few changes to this section of CPT®. Several parenthetical notes have been added to clarify code selection. For instance, a note added to the Stomach: Laparoscopy codes (43644-43659) instructs, “For laparoscopic implantation, revision or removal of gastric neurostimulator electrodes, lesser curvature [morbid obesity], use 43659.” Three new codes (49082-49084) describing abdominal paracentesis replace deleted codes 49080 and 49081. Liver biopsy (47000) now includes moderate sedation, when provided.
There are no changes in the Surgery/Male Genital System portion of CPT®. The Surgery/Female Genital System codes also are unchanged, but several parenthetical notes have been added throughout the section. Among these is instruction to report 11981 for insertion of a non-biodegradable contraception implant, and 11976-11981 for removal with subsequent insertion.
Codes 64622-64627 have been deleted, replaced by 64633-64636 for destruction of paravertebral facet joint by neurolytic agent. The new codes specify location (cervical or thoracic and lumbar or sacral) and the number of joints injected (single and each additional). Many additional code descriptors have undergone revision to better specify the intent or application of the code. For example, the term “array” was added to implantation of neurostimulator code (64553-64565 and 64575-64585) descriptors to clarify that the codes are applied per array, not per individual electrode (an array may contain several electrodes). New parenthetical notes and instructions appear throughout the section.
Eye/Ocular Adnexa and Auditory System
These sections include only minor changes, including new parenthetical instructions (e.g., “For fitting of contact lens for treatment of disease, see 92071, 92072”) and the deletion of 69802 Labyrinthotomy, with perfusion of vestibuloactive drug(s); with mastoidectomy.
Of the many changes to the Radiology section, the most significant include the creation of new codes to report intra-operative radiation treatment delivery (77424, 77425) and intra-operative radiation treatment management (77469). New instructions specify that radiation treatment management is reported in units of five fractions or treatment sessions, regardless of the actual time period in which the services are furnished.
Atherectomy codes 75992-75996 have been deleted and replaced with other codes. For instance, in 2012, in place of 75995, use Category III code 0235T Transluminal peripheral atherectomy, open or percutaneous, including radiological supervision and interpretation; visceral artery (except renal), each vessel.
Path and Lab
CPT® 2012 establishes an entirely new section for molecular pathology, including two full pages of instruction and dozens of new codes for Tier 1 (81200-81383) and Tier 2 (81400-81408) molecular pathology procedures. Molecular pathology procedures involve analyses of nucleic acid to detect variants in genes that may be indicative of germline or somatic conditions, or to test for histocompatibility antigens. Code selection is based on the specific gene analyzed.
Parenthetical notes now accompany HIV-1 and HIV-2 testing code 86703 (single result) to clarify proper coding for alternative testing, such as HIV-1 antigens(s) with HIV-1 and HIV-2 antibodies (87389), and when to apply modifier 92 with 86701-86703 and 87389.
Descriptor revisions clarify immunization coding (90460, +90461) by vaccine component, rather than per injection. Esophageal motility studies will no longer be reported with 91011 or 91012; instead, you will use revised codes 91010 (for motility study) and +91013 (an add-on code for stimulation or perfusion). Code 92070 is deleted and replaced by two new codes (92071 and 92072) for contact lens fitting to treat ocular surface disease or to manage keratoconus, respectively.
A full page of instructions has been added for sleep medicine testing, and new codes have been added to report needle electromyography, per extremity (95885, limited; and 95886, complete) or non extremity (95887). Hydration codes (96360 and +93631) also come with significant additional instructions in 2012, to better explain the meaning of “initial infusion,” “sequential infusion,” and “concurrent infusion.”
Good weather, a good friend, and a good codebook—what more does a girl need?
Category III Codes
Over 30 new Category III codes have been added to CPT® 2012, including those for intramuscular autologous bone marrow cell therapy (0263T-0265T), percutaneous laminotomy/laminectomy (0274T, 0275T), corneal incision (0289T, 0290T), and more. Category III codes describe emerging technologies and, unlike Category I “unlisted procedure” codes, allow for tracking and collection of specific data. If a Category III code is available, it must be reported instead of a Category I unlisted procedure code.
Look for more: We’ll be covering specific information on individual CPT® code changes in upcoming issues of Coding Edge.
Raemarie Jimenez, CPC, CPMA, CPC-I, CANPC, CRHC, is AAPC director of education, and a member of the CPT® Health Care Professionals Advisory Committee (HCPAC).
December 1st, 2011