2015 CPT coding changes will have mixed effects on payment for general surgeons

Significant changes in Current Procedural Terminology (CPT)* coding are being implemented in 2015, although not all of these changes were accepted by the Centers for Medicare & Medicaid Services (CMS). This article provides reporting and payment information about the codes that are relevant to general surgery and its closely related specialties.

Lower GI endoscopy

Coding tip
Use modifier 52 (reduced services) for an incomplete exam for a therapeutic procedure when the cecum is not reached. For a diagnostic or screening exam when it is not possible to reach the cecum, use modifier 53 (discontinued procedure), which allows the procedure to be repeated and reimbursed on another date.

A number of revisions were made to the lower gastrointestinal (GI) endoscopy codes in the Colon and Rectum subsection of CPT. Definitions were revised or added at the beginning of the subsection and new guidelines were created to further clarify reporting of these procedures:

  • Colonoscopy is the examination of the entire colon, from the rectum to the cecum, and may include examination of the terminal ileum or small intestine proximal to an anastomosis.
  • Colonoscopy through stoma is the examination of the colon, from the colostomy stoma to the cecum, and may include examination of the terminal ileum or small intestine proximal to an anastomosis.
  • When performing a diagnostic or screening endoscopic procedure on a patient who is scheduled and prepared for a total colonoscopy, if the physician is unable to advance the colonoscope to the cecum or colon-small intestine anastomosis due to unforeseen circumstances, report 45378 (colonoscopy) or 44388 (colonoscopy through stoma) with modifier 53 (discontinued procedure) and provide appropriate documentation.
  • If a therapeutic colonoscopy (44389–44407, 45379, 45380, 45381, 45382, 45384, 45388, 45398) is performed and does not reach the cecum or colon-small intestine anastomosis, report the appropriate therapeutic colonoscopy code with modifier 52 (reduced services) and provide appropriate documentation.
  • Report flexible sigmoidoscopy (45330–45347) for endoscopic examination during which the endoscope is not advanced beyond the splenic flexure.
  • Report flexible sigmoidoscopy (45330–45347) for endoscopic examination of a patient who has undergone resection of the colon proximal to the sigmoid (eg, subtotal colectomy) and has an ileo-sigmoid or ileo-rectal anastomosis. Report pouch endoscopy codes (44385, 44386) for endoscopic examination of a patient who has undergone resection of colon with ileo-anal anastomosis (eg, J-pouch).
  • Report colonoscopy (45378–45398) for endoscopic examination of a patient who has undergone segmental resection of the colon (eg, hemicolectomy, sigmoid colectomy, low anterior resection).
  • For colonoscopy through stoma, see 44388–44408.Report proctosigmoidoscopy (45300–45327), flexible sigmoidoscopy (45330–45347), or anoscopy (46600, 46604, 46606, 46608, 46610, 46611, 46612, 46614, 46615), as appropriate for endoscopic examination of the defunctionalized rectum or distal colon in a patient who has undergone colectomy, in addition to colonoscopy through stoma (44388–44408) or ileoscopy through stoma (44380, 44381, 44382, 44384) if appropriate.

As part of the review of the lower GI endoscopy codes, several stent placement and ablation CPT codes were deleted and new CPT codes were created that added the words “pre- and post-dilation and guide wire passage, when performed” to the descriptor. In addition, new CPT codes were created for reporting new technology, such as endoscopic hemorrhoid banding.

Category III codes 0226T and 0227T were converted to Category I codes 46601 and 46607. Typically either a colposcope or operating microscope is used for visualization and cannot be separately reported.

In the Medicare physician fee schedule (MPFS) final rule, discussed in detail in this issue, CMS rejected the recommended CPT code changes and the American Medical Association Relative Value Scale Update Committee (RUC) work relative value unit (RVU) recommendations. Instead, CMS decided to maintain the 2014 code descriptors and the 2014 work RVUs for calendar year (CY) 2015.

Because the code set is changing for CY 2015, including the deletion of some of the CY 2014 codes, CMS created temporary “G-codes” to allow practitioners to report services to CMS in CY 2015 using the same code descriptors they used in CY 2014 (that is, providers must report the 2015 G-code for Medicare patients in lieu of the deleted 2014 code). All Medicare payment policies applicable to the CY 2014 CPT codes will apply to the replacement G-codes. The new and revised CY 2015 CPT codes for lower GI endoscopy that Medicare will not recognize for payment in CY 2015 are denoted with an “I” (invalid for Medicare purposes).

For Medicare patients, providers should report the appropriate G-code instead of a code that has a status indicator of “I” (see Table 1).

Table 1. Temporary G codes

CY 2015 CPT codes
Not valid for Medicare purposes
CY 2015 HCPCS codes to report for Medicare patients
44381 Ileoscopy, stoma with balloon G6021 Unlisted procedure, intestine
44384 Ileoscopy, stoma with stent G6018 Ileoscopy, stoma with stent
44401 Colonoscopy, stoma with ablation G6019 Colonoscopy, stoma with ablation
44402 Colonoscopy, stoma with stent G6020 Colonoscopy, stoma with stent
44403 Colonoscopy, stoma with EMR G6021 Unlisted procedure, intestine
44404 Colonoscopy, stoma with injection G6021 Unlisted procedure, intestine
44405 Colonoscopy, stoma with dilation G6021 Unlisted procedure, intestine
44406 Colonoscopy, stoma with ultrasound G6021 Unlisted procedure, intestine
44407 Colonoscopy, stoma with fine-needle aspiration/biopsy G6021 Unlisted procedure, intestine
44408 Colonoscopy, stoma with decompression G6021 Unlisted procedure, intestine
45346 Sigmoidoscopy with ablation G6022 Sigmoidoscopy with ablation
45347 Sigmoidoscopy with stent G6023 Sigmoidoscopy with stent
45349 Sigmoidoscopy with endoscopic mucosal resection G6021 Unlisted procedure, intestine
45350 Sigmoidoscopy with band ligation G6021 Unlisted procedure, intestine
45388 Colonoscopy with ablation G6024 Colonoscopy with ablation
45389 Colonoscopy with stent G6025 Colonoscopy with stent
45390 Colonoscopy with endoscopic mucosal resection G6021 Unlisted procedure, intestine
45393 Colonoscopy with decompression G6021 Unlisted procedure, intestine
45398 Colonoscopy with band ligation G6021 Unlisted procedure, intestine
46601 High resolution anoscopy with brushings or washings G6027 High resolution anoscopy with brushings or washings
46607 High resolution anoscopy with biopsy G6028 High resolution anoscopy with biopsy

For patients with private insurance, providers will need to check with the insurers to determine whether they will follow Medicare policy or allow providers to report the new codes. Keep in mind that the new codes do not have published RVUs. Therefore, documentation will be required to support the payment amount for a claim.

The Colonoscopy Decision Tree (see figure) is designed to assist with correct CPT code and modifier selection. There is one correction (highlighted in red) from the CPT 2015 Professional Edition; when a therapeutic procedure to the cecum is performed, report the appropriate colonoscopy code with no modifier. In addition, we have added the Medicare-assigned Healthcare Common Procedure Coding System (HCPCS) G-codes where appropriate under the therapeutic procedure category (highlighted in blue in the figure).

Colonoscopy Decision Tree

*For Medicare patients, report applicable G-code in lieu of CPT codes. For non-Medicare patients, follow insurer instructions. Reprinted with permission, American Medical Association.

Table 2 describes the lower GI endoscopy coding changes for 2015, along with the MPFS status indicator and work RVU. Read more about these coding and payment changes in the final MPFS rule.

Table 2. Lower GI endoscopy coding changes for 2015
(Click on the table to enlarge.)

Table 2

CPT five-digit codes, two-digit number modifiers, and descriptions only are copyright of the AMA. No payment schedules, fee schedules, RVUs, scales, conversion factors, or components thereof are included in CPT. The AMA is not recommending that any specific relative values, fees, payment schedules, or related listings be attached to CPT. Any RVUs or relative listings assigned to CPT codes are not those of the AMA, and the AMA is not recommending use of these relative values.

Injection for fecal incontinence

A new Category III code was established to report injection of a bulking agent to treat fecal incontinence, 0377T, Anoscopy with directed submucosal injection of bulking agent for fecal incontinence. The bulking agent should be reported separately using Level II HCPCS code L8605 and the appropriate number of units for each millileter injected should be indicated.

Treatment of rib fractures

Four Category III codes (0245T–0248T) were converted to three Category I codes (21811–21813) to report open treatment of rib fracture(s) with internal fixation. These new codes include thoracoscopic visualization as inherent and describe unilateral fixation. If fixation is bilateral, modifier 50 should be appended and unit of “1” should be reported. In tandem with the creation of these new codes, several codes were deleted, including 21800, Closed treatment of rib fracture, uncomplicated, each; and code 21810, Treatment of rib fracture requiring external fixation (flail chest). CMS has assigned a 0-day global status to these three new codes. All postoperative hospital and office evaluation and management visits after the day of the procedure should be reported, when performed, using appropriate evaluation and management (E/M) visit codes with documentation. These three new codes include the following:

  • 21811    Open treatment of rib fracture(s) with internal fixation, includes thoracoscopic visualization when performed, unilateral; 1–3 ribs
  • 21812    4–6 ribs
  • 21813    7 or more ribs

Endoscopic hypopharyngeal diverticulotomy

A new code was created to report the endoscopic repair of Zenker’s diverticulum, 43180, Esophagoscopy, rigid, transoral with diverticulectomy of hypopharynx or cervical esophagus (eg, Zenker’s diverticulum), with cricopharyngeal myotomy, includes use of telescope or operating microscope and repair, when performed. For open repair of Zenker’s diverticulum, use 43130, Diverticulectomy of hypopharynx or esophagus, with or without myotomy; cervical approach, or 43135, Diverticulectomy of hypopharynx or esophagus, with or without myotomy; thoracic approach, as appropriate.

Transversus abdominis plane (TAP) anesthetic block

Four Category I codes (64486–64489) were established to report unilateral or bilateral administration of local anesthetic for postoperative pain control and abdominal wall analgesia, including imaging guidance when performed. These codes may not be reported by the same physician who performs the surgical procedure. These four new codes include the following:

  • 64486    TAP block (abdominal plane block, rectus sheath block) unilateral; by injection(s) (includes imaging guidance, when performed)
  • 64487     TAP block by continuous infusion(s) (includes imaging guidance, when performed)
  • 64488    TAP block (abdominal plane block, rectus sheath block) bilateral; by injections (includes imaging guidance, when performed)
  • 64489     TAP block by continuous infusions (includes imaging guidance, when performed)

Breast ultrasound

Codes 76642 and 76645 were deleted and replaced by two new codes to describe ultrasound of the breast (76641, 76642). A complete ultrasound of the breast (76641) includes all four quadrants of the breast, the retroareolar region, and the axilla, if performed. A focused or limited ultrasound of the breast (76642) is limited to one or more of the elements in 76641, but not all of the exam elements. If only an axillary ultrasound is performed, code 76882 is reported. Codes 76641 and 76642 can only be reported once per breast, per session. These two new codes include the following:

  • 76641     Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete
  • 76642     limited

Negative pressure wound therapy

For 2015, the descriptors for codes 97605 and 97606 have been revised to include “durable medical equipment (DME)” to distinguish from two new codes (97607 and 97608), which are intended to report negative pressure wound therapy using non-durable (disposable) medical equipment. In addition, the practice expense RVUs for codes 97607 and 97608 include the disposable supplies and equipment, which should not be separately reported. Codes 97607 and 97608 will be contractor priced for 2015 and will be designated “Sometimes Therapy” on the CMS Therapy Code List. These revised and new codes include the following:

  • 97605    Negative pressure wound therapy (eg, vacuum assisted drainage collection), utilizing durable medical equipment (DME), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters
  • 97606    Total wound(s) surface area greater than 50 square centimeters
  • 97607    Negative pressure wound therapy, (eg, vacuum assisted drainage collection), utilizing disposable, non-durable medical equipment including provision of exudate management collection system, topical application(s), wound assessment, and instructions for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters
  • 97608    Total wound(s) surface area greater than 50 square centimeters

Bioimpedance spectroscopy (BIS)

Category III code 0239T was converted to Category I code 93702, Bioimpedance spectroscopy (BIS), extracellular fluid analysis for lymphedema assessment(s). Code 93702 does not include physician work RVUs, as it was developed to account for practice expense only. The report that is generated is reviewed by the provider as part of an E/M service.

CPT definition of the surgical package

An editorial revision was made to the surgical package to expand the introductory language to indicate that surgery can be furnished by the physician or other qualified health care professional. This is consistent with changes that have been made throughout the CPT code set to be inclusive of other qualified health care professionals. These revisions are editorial and do not reflect new or different work.

Note

Accurate coding is the responsibility of the provider. This summary is intended only to serve as a resource to assist in the billing process.


*All specific references to CPT (Current Procedural Terminology) codes and descriptions are © 2014 American Medical Association. All rights reserved. CPT and CodeManager are registered trademarks of the American Medical Association.

 

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