Highlights of 2006 CPT Updates and OPPS Changes

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Highlights of 2006 CPT Updates and OPPS Changes

• Barry Libman, RHIA, CCS, CCS-P
• President
• Barry Libman Inc.

2
New for 2006

• The AMA has a new logo

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New for 2006

• CPT has a new symbol
• Lightening bolt indicates a vaccine currently
  pending FDA approval
• Check AMA website for updates

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Summary of 2006 CPT Changes

• 18 Evaluation and Management
• 104 Surgery
• 10 Radiology
• 29 Pathology and Laboratory
• 57 Medicine
• 21 Category II
• 35 Category III
• Total 274 New Codes
• Also, 70 revisions and 107 deletions

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Evaluation and Management

• Nursing Facility Care Services (SNF, ICF, LTCF)
• 99304 99310 Initial, Subsequent, New,
  Established
• Domiciliary, Rest Home, Custodial Care
• 99324 99340 New, Established

6
Skin Replacement Surgery and Skin
Substitutes

• 15040 Harvest of skin for tissue cultured skin
  autograft, 100 sq cm or less
• 15110 - 15116 Epidermal Autograft (T)
• 15130 - 15136 Dermal Autograft (T)
• 15150 - 15157 Tissue Cultured Dermal Autograft
  (T)
• 15170 - 15176 Tissue Cultured Epidermal Autograft
  (T)

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Skin Replacement Surgery and Skin
Substitutes

• 15300 - 15321 Allograft Skin for Temporary Wound
  Closure (T)
• 15330 - 05336 Acellular Dermal Allograft (T)
• 15340 - 15341 Tissue Cultured Allogeneic Skin
  Substitute (T)
• 15360 - 15366 Tissue Cultured Allogeneic Dermal
  Substitute (T)
• 15420 - 15421 Xenograft Dermal for Temporary
  Wound Closure (T)
• 15430 - 15431 Acellular Xenograft Implant (T)

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Surgery

• 22523 Percutaneous vertebral augmentation,
  including cavity creation (fracture reduction and
  bone biopsy included when performed) using
  mechanical device, one vertebral body, unilateral
  or bilateral cannulation (eg, kyphoplasty)
  thoracic (T)
• 22524 lumbar (T)
• 22525 each additional thoracic or lumbar
  vertebral body (List separately in addition to
  code for primary procedure) (T)

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Surgery

• 28890 Extracorporeal shock wave, high energy,
  performed by a physician, requiring anesthesia
  other than local, including ultrasound guidance,
  involving the plantar fascia (T)
• 36598 Contrast injection(s) for radiologic
  evaluation of existing central venous access
  device, including fluoroscopy, image
  documentation and report (X)

10
Surgery

• 37184 Primary percutaneous transluminal
  mechanical thrombectomy, noncoronary, arterial or
  arterial bypass graft, including fluoroscopic
  guidance and intraprocedural pharmacological
  thrombolytic injection(s) initial vessel (T)
• 37185 second and all subsequent vessel(s)
  within the same vascular family (List separately
  in addition to code for primary mechanical
  thrombectomy procedure) (T)

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Surgery

• 37186 Secondary percutaneous transluminal
  thrombectomy (e.g., nonprimary mechanical, snare
  basket, suction technique), noncoronary, arterial
  or arterial bypass graft, including fluoroscopic
  guidance and intraprocedural pharmacological
  thrombolytic injections, provided in conjunction
  with another percutaneous intervention other than
  primary mechanical thrombectomy (List separately
  in addition to code for primary procedure) (T)

12
Surgery

• 37186 Secondary Arterial Mechanical Thrombectomy
• Rescue mechanical thrombectomy
• Always performed in conjunction with another
  percutaneous intervention (e.g. percutaneous
  transluminal balloon angioplasty, stent
  placement)

13
Surgery

• 37187 Percutaneous transluminal mechanical
  thrombectomy, vein(s), including intraprocedural
  pharmacological thrombolytic injections and
  fluoroscopic guidance (T)
• 37188 repeat treatment on subsequent day
  during course of thrombolytic therapy (T)

14
Surgery

• 37718 Ligation, division, and stripping, short
  saphenous vein (T)
• 37722 Ligation, division, and stripping, long
  (greater) saphenous veins from saphenofemoral
  junction to knee or below (T)

15
Surgery

• 43886 Gastric restrictive procedure, open
  revision of subcutaneous port component only (T)
• 43887 Gastric restrictive procedure, open
  removal of subcutaneous port component only (T)
• 43888 Gastric restrictive procedure, open
  removal and replacement of subcutaneous port
  component only (T)

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Surgery

• 44180 Laparoscopy, surgical, enterolysis
  (freeing of intestinal adhesion) (separate
  procedure) (T)
• 44186 jejunostomy (e.g., for decompression or
  feeding) (T)
• 44187 ileostomy or jejunostomy, non-tube (T)
• 44188 colostomy or skin level cecostomy (T)
• 44213 mobilization (take-down) of splenic
  flexure performed in conjunction with partial
  colectomy (List separately in addition to primary
  procedure) (T)
• 45499 Unlisted laparoscopy procedure, rectum (T)

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Surgery

• 45990 Anorectal exam, surgical, requiring
  anesthesia (general, spinal, or epidural),
  diagnostic (T)
• 46505 Chemodenervation of internal anal
  sphincter (T)

18
Surgery

• 50382 Removal (via snare/capture) and
  replacement of internally dwelling ureteral stent
  via percutaneous approach, including radiological
  supervision and interpretation (T)
• 50384 Removal (via snare/capture) of internally
  dwelling ureteral stent via percutaneous
  approach, including radiological supervision and
  interpretation (T)
• 50387 Removal and replacement of externally
  accessible transnephric ureteral stent (e.g.,
  external/internal stent) requiring fluoroscopic
  guidance, including radiological supervision and
  interpretation (T)
• 50389 Removal of nephrostomy tube, requiring
  fluoroscopic guidance (e.g., with concurrent
  indwelling ureteral stent) (T)

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Surgery

• 50592 Ablation, one or more renal tumor(s),
  percutaneous, unilateral, radiofrequency (T)
• 51999 Unlisted laparoscopy procedure, bladder
  (T)
• 57295 Revision (including removal) of prosthetic
  vaginal graft, vaginal approach (T)
• 58110 Endometrial sampling (biopsy) performed
  in conjunction with colposcopy (List separately
  in addition to code for primary procedure) (T)

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Surgery

• 64650 Chemodenervation of eccrine glands both
  axillae (T)
• 64653 Chemodenervation of eccrine glands other
  area(s) (e.g., scalp, face, neck), per day (T)

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This could save your life !

• Previously, code 82270 failed to distinguish
  between a single specimen fecal occult blood test
  (FOBT) that is primarily done in the office
  setting, e.g., after a digital rectal exam, and a
  threespecimen FOBT that the patient typically
  collects at home.
• Three-specimen determination is essential for
  proper screening.

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Laboratory

• 82270 Blood occult, by peroxidase activity
  (e.g., guaiac), qualitative feces, consecutive
  collected specimens with single determinations,
  for colorectal neoplasm screening (i.e., patient
  was provided three cards or single triple card
  for consecutive collection) (A)
• 82271 other sources (A)
• 82272 Blood, occult, by peroxidase activity
  (e.g., guaiac), qualitative, feces, single
  specimen (e.g., from digital rectal exam) (A)

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Laboratory

• 86923 Compatibility test each unit electronic
  (X)
• 86960 Volume reduction of blood or blood product
  (e.g., red blood cells or platelets), each unit
  (X)
• 88333 Pathology consultation during surgery
  cytologic examination (e.g., touch prep, squash
  prep), initial site (X)
• 88334 each additional site (X)

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Infusion Drug AdministrationA little history

• Pre-APC
• Medicare/Non-Medicare used same code set
• APC
• Medicare used Q codes
• Non-Medicare established CPT Codes
• 2005
• Medicare deleted Q code
• Medicare and Non-Medicare used established CPT
  codes
• 2006
• Medicare used new C Codes
• Non-Medicare created new CPT code set
• Transmittal and Program Memoradum have not been
  released yet
• (see Crosswalk)

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How to Code Hydration, Drug and Chemo.

• Ask yourself four questions
• 1. Why was the patient seen?
• 2. What did we give them?
• 3. How did we give it?
• 4. How long did it take?

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How to Code Hydration, Drug and Chemo. Ask
yourself four questions

• 1. Why was the patient seen? (The primary reason
  for the visit.)
• New patient for antibiotic, IVIG, other drug
  treatment but will likely have an associated EM
  code billed as well
• Return patient will likely have no or a lower EM
  code billed
• Routine follow-up, but needs hydration
• Determine which initial code to use

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How to Code Hydration, Drug and Chemo. Ask
yourself four questions

• 2. What did we give them?
• Hydration
• Antibiotic or other drug
• Chemo
• Simple or complicated
• J Code(s) for fluids, drugs/substances, chemo
• Determine what J code(s) to bill

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How to Code Hydration, Drug and Chemo. Ask
yourself four questions

• 3. How did we give it?
• IV Infusion
• IV push
• SQ/IM injection
• Some combination
• Determine which administration code(s) to bill
  and if there are subsequent services

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How to Code Hydration, Drug and Chemo. Ask
yourself four questions

• 4. How long did it take?
• 5 or gt15 minutes (push vs. infusion)
• One hour
• Additional hours
• Infusion time is measured when the infusate is
  actually running
• Pre- and post-time are not counted
• Good idea to document infusion start/stop times

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Medicine- Hydration, Therapeutic, Prophylactic
and Diagnostic Injections (excludes Chemotherapy)

• 90760 Intravenous infusion, hydration initial,
  up to 1 hour (B)
• 90761 each additional hour, up to 8 hours
  (List separately in addition to code for primary
  procedure) (B)
• 90765 Intravenous infusion, for therapy,
  prophylaxis, or diagnosis (specify substance or
  drug) initial, up to 1 hour (B)
• 90766 each additional hour, up to 8 hours
  (List separately in addition to code for primary
  procedure) (B)
• 90767 additional sequential infusion, up to 1
  hour (List separately in addition to code for
  primary procedure) (B)
• 90768 concurrent infusion (List separately in
  addition to code for primary procedure) (B)

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Medicine- Hydration, Therapeutic, Prophylactic
and Diagnostic Injections (excludes Chemotherapy)

• 90772 Therapeutic, prophylactic or diagnostic
  injection (specify substance or drug)
  subcutaneous or intramuscular (X)
• 90773 intra-arterial (X)
• 90774 intravenous push, single or initial
  substance/drug (B)
• 90775 each additional sequential intravenous
  push of a new substance/drug (List separately in
  addition to code for primary procedure) (B)
• 90779 Unlisted therapeutic, prophylactic or
  diagnostic intravenous or intra-arterial
  injection or infusion (X)

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Medicine - Injection and Intravenous Infusion
Chemotherapy

• 96401 Chemotherapy administration, subcutaneous
  or intramuscular non-hormonal anti-neoplastic
  (S)
• 96402 hormonal anti-neoplastic (S)
• 96409 Chemotherapy administration intravenous,
  push technique, single or initial substance/drug
  (B)
• 96411 each additional substance/drug (List
  separately in addition to code for primary
  procedure) (B)

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Medicine - Injection and Intravenous Infusion
Chemotherapy

• 96413 Chemotherapy administration, intravenous
  infusion technique up to 1 hour, single or
  initial substance/drug (B)
• 96415 each additional hour, 1 to 8 hours
  (List separately in addition to code for primary
  procedure) (B)
• 96416 initiation of prolonged chemotherapy
  infusion (more than 8 hours), requiring use of a
  portable or implantable pump (S)
• 96417 each additional sequential infusion
  (different substance/drug), up to 1 hour (List
  separately in addition to code for primary
  procedure) (B)

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Medicine - Injection and Intravenous Infusion
Chemotherapy

• C8950 Intravenous infusion for therapy/diagnosis
  up to 1 hour (S)
• C8951 each additional hour (N)
• C8952 Therapeutic, prophylactic or diagnostic
  injection intravenous push (X)
• C8953 Chemotherapy administration, intravenous
  push technique (S)
• C8954 infusion technique, up to 1 hour (S)
• C8955 each additional hour (list separately in
  addition to C8954) (N)

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Medicine - Other Chemotherapy

• 96521 Refilling and maintenance of portable pump
  (T)
• 96522 implantable pump or reservoir for drug
  delivery, systemic (e.g., intravenous,
  intra-arterial) (T)
• 96523 Irrigation of implanted venous access
  device for drug delivery systems (N)

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Medicine - Other Chemotherapy

• C8956 Refilling and maintenance of portable or
  implantable pump or reservoir for drug delivery
  for therapy/diagnosis, systemic (e.g.,
  intravenous, intra-arterial) (T)
• C8957 Intravenous infusion for therapy/diagnosis
  initiation of prolonged infusion (more than 8
  hours), requiring use of portable or implantable
  pump (S)

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Hydration, Chemo and Non-Chemo Drug Administration

• If
• Infusion CPT code with a status indicator of (S)
  or (T)
• AND
• an EM visit on the same day of service
• amend Modifier 25 to the EM level

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Observation

• G0244, G0263, G0264 deleted, replaced with
• G0378 hospital observation service per hour
• G0379 direct admission of a patient for hospital
  observation care
• (changes from per-day to per-hour)
• Criteria for separately payable Observation
• Diagnosis of CHF, chest pain or asthma (no change
  from last year)
• G0378 and/or G0379 with no (T) or (V) CPT codes
• Transmittal and Program Memoradum have not been
  released yet

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Device Dependent APC

• Device coding is mandatory
• In 2006, CCI edits unchanged from 2005
• In 2007, it is expected that the CCI edits
  indicating that the device code is missing will
  be removed
• As always, reporting device codes today will
  affect reimbursement in the future

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Device Dependent APC

• Modifier FB, new 1/1/06
• Append Modifier FB
• to device code when device provided to facility
  at no charge
• to a device dependent procedure code when no
  device used
• 70 FR 68622

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Wound Therapy

• G0281 and G0329 are defined as always therapy
• Always
• Provided under a therapy plan of care
• Billed with a therapy modifier (GP, GO, or GN)
• Billed with therapy revenue code (42x, 43x, or
  44x)
• (A), paid under Medicare Physician Fee Schedule

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Wound Therapy

• 97597, 97598, 97602, 97605, 97606 defined as
  sometimes therapy, sometimes medical
• If therapy
• Rendered by a therapist or provided under a
  therapy plan of care
• Billed with a therapy modifier (GP, GO, or GN)
• Billed with therapy revenue code (42x, 43x, or
  44x)
• (A), paid under Medicare Physician Fee Schedule
• If medical
• Not rendered under a therapy plan of care
• (X) or (T), paid under OPPS

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Intravenous infusion of immunoglobulin (IVIG)

• G0332 pre-administration-related services for
  intravenous infusion of immunoglobulin, per
  infusion encounter
• This is a separate payment to hospitals to
  reflect additional resources associated with
  acquiring adequate IVIG products
• Must be billed in conjunction with administration
  of immunoglobulin, one per day allowed
• G0332 is not yet included in the standard HCPCS
  table on the CMS website -- Bill it anyway

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OPPS Highlights Urinary Cath

• Be certain to bill these codes!
• 51701 Insertion Non-Indwelling Bladder Catheter
  (X)
• 51702 Insertion Temporary Indwelling Bladder
  Catheter Simple (X)
• 51703 Insertion Temporary Indwelling Bladder
  Catheter Complicated (T)
• Previously status N in 2005
• 70 FR 68544

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OPPS Highlights - Smoking

• Smoking Cessation Counseling
• G0375 Smoking and Tobacco Use Cessation
  Counseling Visit Intermediate, Greater than 3
  minutes up to 10 minutes (S)
• G0376 Intensive, Greater than 10 minutes (S)
• Add to E/M code for visit with modifier 25
• Service cannot be done by Respiratory Therapist
• 70 FR 68583

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OPPS highlights Modifier 52

• Modifier 52 is to be used for
• reduced services (any discipline)
• discontinued radiology services that do not
  require anesthesia
• 2005 paid at 100
• 2006 paid at 50
• 70 FR 68710

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OPPS Highlights ER and Clinic EM

• Emergency Room and Clinic Evaluation and
  Management Services
• Testing Draft Guidelines recommended by the
  independent Hospital Evaluation and Management
  Coding Panel is still underway
• In accordance with CMS Policy established in the
  Final Rule April 7, 2000, hospitals should
  continue to use internal guidelines to
  distinguish different levels of resource
  intensity when determining appropriate CPT codes
  to bill for outpatient E/M services.
• 70 FR 68684

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Now what?

• Read the Federal Register
• Read CPT book
• Share information with others in your facility
• Questions?
• Barry Libman
• 978-369-7180
• barry_at_barrylibmaninc.com