CPT 2012 brings with it new codes and code changes

The Current Procedural Terminology (CPT)* 2012 manual comprises several new codes and code changes pertaining to general surgery and its closely related specialties. This article summarizes these modifications.

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New modifier

The Affordable Care Act (ACA) requires all health care plans to begin covering immunizations and preventive services without any cost sharing. Modifier 33 has been added to CPT 2012 to identify preventive services. This modifier allows providers to identify that the service was preventive under applicable laws and that patient cost sharing does not apply.

Evaluation and management

The new and established patient definitions in the evaluation and management (E/M) guidelines have been revised to add additional granularity to the terms “specialties” and “subspecialties.” The term “exact subspecialty” was added to specify that the professional services would be provided by a physician of the exact same specialty and subspecialty, who belongs to the same group practice, within the past three years. This revision clarifies that although the physician may be of the same specialty, differences between the subspecialty may require a significant new patient work-up and should therefore be considered a new patient visit rather than an established patient visit.

Debridement

As a point of clarification, in 2011 the debridement guidelines stated that add-on code 11045, Debridement, subcutaneous tissue (includes epidermis and dermis, if performed; each additional 20 sq cm, or part thereof, should be reported with modifier 59, if multiple wounds are debrided on the same day. However, add-on codes do not require the use of a modifier. The 2012 revised guidelines now indicate that coders should use modifier 59 with either 11042, Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less) or 11044, Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm or less, as appropriate.

Skin replacement surgery

Comprehensive changes have been made to the skin replacement surgery subsection. The changes include deletion of 24 codes, revision of six codes, and the creation of eight new codes (15271–15278). This article gives only a brief overview of the changes; a more detailed skin replacement surgery article will be published in February.

Reference to the phrase “skin substitutes” has been removed as a subheading in the skin replacement surgery section; the codes in this section are now in a new section in the manual, referred to as “skin substitute grafts.” However, some codes remain in the skin replacement surgery section, including surgical preparation; topical placement of an autograft; tissue-cultured autograft; and skin substitute homograft, allograft, and xenograft. The guidelines instruct that the graft is anchored using the provider’s choice of fixation, and when services are performed in the office, routine dressing supplies are not reported separately.

HIGHLIGHT
CMS recently provided a clarification on observation codes. More specifically, Medicare now has explicit rules related to the billing of subsequent observation codes (99224–99226). These rules are specific to Medicare and do not follow current CPT guidance. Note that private payors may or may not follow these guidelines.Under Medicare’s guidelines, only the physician who admits a patient for observation may bill the subsequent observation codes. Thus, subsequent observation care is only rendered by the admitting physician on the day(s) other than the initial or discharge date. Physicians who provide consultations while a patient is admitted to hospital outpatient observation services must bill the appropriate outpatient evaluation and management service (99201–99215).Additionally, subsequent observation codes will be included in the global surgical fee. Thus, only services that meet the criteria to append modifier 24, unrelated evaluation and management, post-operative, same physician; 25, separate, significant evaluation and management, same physician and same day; or 57, decision for surgery, to the evaluation and management service may be billed to Medicare in a global period.

Other flaps and grafts

A new add-on code 15777, Implantation of biologic implant (eg, acellular dermal matrix) for soft tissue reinforcement (eg, breast, trunk), has been established. For bilateral breast procedures, report 15777 with modifier 50. For implantation of synthetic mesh or other prosthesis for open incisional or ventral hernia repair or closure of a necrotizing soft tissue infection wound, report 49568 in conjunction with 49560–49566 or 11004–11006, as appropriate. Code 15777 is not to be used for the topical application of skin substitute graft to a wound surface, which should be reported with new codes 15271–15278.

Hands and fingers

Two new codes are available to report the treatment of Dupuytren’s contracture. Report code 20527 for the injection of an enzyme (for example, collagenase) into the palmar fascial cord (ie, Dupuytren’s cord). Code 26341 is reported for the manipulation of the palmar fascial cord performed on the next day and follow-up care within 10 days (for example, wound check). Fabrication and application of a custom orthotic is separately reportable.

Lungs and pleura

Comprehensive changes were made to the lungs and pleura section of CPT, including a new section added to identify video-assisted thoracoscopic surgery (VATS).

The guidelines provide specific instructions when the services of intraoperative pathology are used. In these circumstances, if a more extensive procedure is required due to the results of the consultation, then only the most extensive procedure code is reported. The new guidelines prohibit use of smaller procedure codes, such as biopsies, in addition to more extensive lung procedure codes such as lobectomies, unless the procedures were performed on different lobes, or the contralateral lung. In these situations it would be appropriate to append the 59 modifier (distinct procedural service).

Code 32095—previously used to report biopsy procedures of the lungs or pleura via thoracotomy— has been deleted. Three new codes are available to report incisional (thoracotomy) biopsy procedures: 32096, Thoracotomy, with diagnostic biopsy(ies) of lung infiltrate(s) (eg, wedge, incisional), unilateral; 32097, Thoracotomy, with diagnostic biopsy(ies) of lung nodule(s) or mass(es) (eg, wedge, incisional), unilateral; and 32098, Thoracotomy, with biopsy(ies) of pleura.

Therapeutic wedge resection procedures are now reported with 32505, Thoracotomy; with therapeutic wedge resection (eg, mass, nodule), initial.

Two new add-on codes for open wedge resection have been created: 32506, Therapeutic wedge resection (eg, mass or nodule), each additional resection, ipsilateral (List separately in addition to code for primary procedure), and 32507, Diagnostic wedge resection followed by anatomic lung resection (List separately in addition to code for primary procedure).

In CPT 2012, the term “video-assisted thoracoscopic surgery” (VATS) replaces “thoracoscopy.” CPT code 32602, Thoracoscopy, diagnostic (separate procedure); lungs and pleural space, with biopsy, has been deleted. Three new codes have been created to report lung or pleural space biopsy procedures: 32607, Thoracoscopy; with diagnostic biopsy(ies) of lung infiltrate(s) (eg, wedge, incisional, unilateral); 32608, Thoracoscopy; with diagnostic biopsy(ies) of lung nodule(s) or mass(es) (eg, wedge, incisional), unilateral; and 32609, Thoracoscopy; with biopsy(ies) of pleura. Codes 32607 and 32608 should not be reported more than once per lung.

Code 32666 identifies an initial therapeutic wedge resection using VATS. If performed bilaterally, modifier 50 may be appended to the code.

Add-on code 32667 is used to report additional thoracoscopic therapeutic wedge resections. Add-on code 32668 is used to report diagnostic wedge resection that is followed by anatomic lung resection. Code 32668 can only be reported in conjunction with CPT codes 32440, 32442, 32445, 32480, 32482, 32484, 32486, 32488, 32503, 32504, 32663, 32669, 32670, and 32671.

New codes 32669–32674 are for VATS removal procedures that vary according to the amount of tissue removed or in the difficulty of removal. CPT code 32674, Thoracoscopy, surgical; with mediastinal and regional lymphadenectomy, is an add-on code, which can only be reported in conjunction with 32440, 32442, 32445, 32480, 32482, 32484, 32486, 32488, 32503, 32504, 32505, 32663, 32666, 32667, 32669, 32670, and 32671. For procedures on the right lung, mediastinal lymph nodes include the paratracheal, subcarinal, paraesophageal, and those in the inferior pulmonary ligament. For procedures on the left lung, mediastinal lymph nodes include the subcarinal, paraesophageal, and those in the aortopulmonary window, and inferior pulmonary ligament.

A surgeon plans to perform a VATS wedge biopsy of two suspicious lesions in the right lung: one in the upper lobe and one in the lower lobe. His plan is to proceed with a therapeutic operation if the frozen section biopsy of either lesion proves to be malignant. The upper lobe lesion is a non-small cell carcinoma on frozen section of the wedge biopsy. The lower lobe lesion is a benign granuloma. The surgeon proceeds to perform a VATS upper lobectomy and mediastinal lymphadenectomy. Reportable codes include the following:

32663, VATS lobectomy
+32668, VATS diagnostic wedge resection
+32667, VATS additional wedge resection
+32674, VATS mediastinal and regional lymphadenectomy

Note: Code 32663 is the primary code. The other codes are add-on codes and do not require modifiers.

IVC filter and ligation of the vena cava

Codes 37620, Interruption, partial or complete, of inferior vena cava by suture, ligation, plication, clip, extravascular, intravascular (umbrella device), and 75940, Percutaneous placement of IVC filter, radiological supervision and interpretation, have been deleted for 2012. Three new bundled codes were established to report insertion, repositioning, and removal of an inferior vena cava (IVC) filter: 37191, Insertion of intravascular vena cava filter, endovascular approach including vascular access, vessel selection, and radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance (ultrasound and fluoroscopy), when performed; 37192, Repositioning of intravascular vena cava filter, endovascular approach including vascular access, vessel selection, and radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance (ultrasound and fluoroscopy), when performed; and 37193, Retrieval (removal) of intravascular vena cava filter, endovascular approach including vascular access, vessel selection, and radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance (ultrasound and fluoroscopy), when performed.

New code 37619, Ligation of inferior vena cava, has been established to report the open surgical procedure performed in trauma patients or other acute open ligation indications.

Paracentesis and peritoneal lavage

In 2012, codes 49080, Peritoneocentesis, abdominal paracentesis, or peritoneal lavage (diagnostic or therapeutic); initial, and 49081, Peritoneocentesis, abdominal paracentesis, or peritoneal lavage (diagnostic or therapeutic); subsequent, have been deleted and replaced with new codes that indicate whether it was done with or without imaging guidance: 49082, Abdominal paracentesis (diagnostic or therapeutic; without imaging guidance), and 49083, Abdominal paracentesis (diagnostic or therapeutic); with imaging guidance.

Additionally, a new code was created to report peritoneal lavage, 49084, Peritoneal lavage, including imaging guidance, when performed.

Medicare physician fee schedule

In addition to coding changes for 2012, the final rule for the Medicare physician fee schedule makes many changes to the physician work relative value units (wRVUs). The changes in wRVUs from 2011 values come after review of procedures and services that the Centers for Medicare & Medicaid Services (CMS) identified as “potentially misvalued,” and for procedures and services identified by specialties as undervalued and reviewed through the five-year review process. The American College of Surgeons was involved in the American Medical Association/Specialty Society Relative Value Scale Update Committee (RUC) survey and review of 95 codes. Although some of these codes decreased in value by as much as 13 percent, other codes increased by as much as 124 percent.

The table presents 42 general surgery codes and nine observation service codes with wRVUs that CMS is changing in 2012. As more hospitals assign patients to outpatient status for facility fee reimbursement instead of inpatient status, it is important to note that CMS agreed to value observation (outpatient) E/M codes equal to the corresponding inpatient E/M codes.

If you have additional coding questions, contact the ACS Coding Hotline at 800-227-7911 between 7:00 am and 4:00 pm Mountain time, excluding holidays.


Editor’s note
Accurate coding is the responsibility of the provider. This summary is only a resource to assist in the billing process.


*All specific references to CPT (Current Procedural Terminology) terminology and phraseology are © 2012 American Medical Association. All rights reserved.

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