2016 CPT coding changes and their effects

Significant Current Procedural Terminology (CPT)* coding changes are being implemented in 2016. Notably, some of these changes reverse last year’s temporary coding for endoscopy procedures. This article provides reporting and payment information about the codes that are relevant to general surgery and its related specialties.

Lower GI endoscopy

The American Medical Association (AMA) CPT Editorial Panel revised the lower gastrointestinal (GI) endoscopy code set for 2015, which required a review of physician work values within the Medicare physician fee schedule (MPFS) final rule. As that change was under review in 2014, the American College of Surgeons, the American Society of Colon and Rectal Surgeons, the Society of American Gastroenterological Surgeons, and several gastrointestinal medical societies conducted AMA/Specialty Society Relative Value Scale Update Committee (RUC) surveys for physician work and offered their recommendations. However, the RUC as a whole disagreed with the specialty recommendations and proposed different values for some of the codes.

The RUC submitted its recommendations on the physician work relative value units (RVUs) for calendar year 2015 to the Centers for Medicare & Medicaid Services (CMS). However, CMS delayed implementing changes to the values for the lower GI codes, citing the new process for including proposed values for new, revised, and potentially misvalued codes in the proposed rule (instead of the final rule) as one reason for the delay. In concert with this decision, CMS implemented temporary Healthcare Common Procedure Coding System (HCPCS) G-codes for a number of the new lower GI endoscopy procedures.

For calendar year 2016, CMS has deleted the G-codes and accepted the CPT codes for reporting the newly defined procedures. CMS also has implemented new RVUs for the entire set of lower GI endoscopy codes using an incremental difference methodology that differs from the RUC and society recommendations for some of the codes. An incremental methodology uses a base code or other comparable code and considers what the difference should be between that code and another code by comparing the incremental differential.

Table 1 presents the lower GI endoscopy code set for 2016, along with a comparison of the 2015 and 2016 MPFS work RVUs. To read more about these coding and payment changes in the final MPFS rule, go to the CMS website.

Table 1. 2015–2016 Lower GI Endoscopy Coding and Work RVU Changes

CPT code Descriptor 2015
work
RVU
2016
work
RVU
Percent
change
Ileoscopy, through stoma

44380

Ileoscopy, through stoma; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)

1.05

0.97

–8%

44381

Ileoscopy, through stoma; with transendoscopic balloon dilation

0.00*

1.48

n/a

44382

Ileoscopy, through stoma; with biopsy, single or multiple

1.27

1.27

0

44384

Ileoscopy, through stoma; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed)

2.94

2.95

0

Endoscopic evaluation of small intestinal pouch

44385

Endoscopic evaluation of small intestinal pouch (eg, Kock pouch, ileal reservoir [S or J]); diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)

1.82

1.30

–29

44386

Endoscopic evaluation of small intestinal pouch (eg, Kock pouch, ileal reservoir [S or J]); with biopsy, single or multiple

2.12

1.60

–25

Colonoscopy through stoma

44388

Colonoscopy through stoma; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)

2.82

2.82

0

44388–53

Colonoscopy through stoma; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)

n/a

1.41

n/a

44389

Colonoscopy through stoma; with biopsy, single or multiple

3.13

3.12

0

44390

Colonoscopy through stoma; with removal of foreign body(s)

3.82

3.84

1

44391

Colonoscopy through stoma; with control of bleeding, any method

4.31

4.22

–2

44392

Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps

3.81

3.63

–5

44394

Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique

4.42

4.13

–7

44401

Colonoscopy through stoma; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed)

4.83

4.44

–8

44402

Colonoscopy through stoma; with endoscopic stent placement (including pre- and post-dilation and guide wire passage, when performed)

4.70

4.80

2

44403

Colonoscopy through stoma; with endoscopic mucosal resection

0.00*

5.60

n/a

44404

Colonoscopy through stoma; with directed submucosal injection(s), any substance

0.00*

3.12

n/a

44405

Colonoscopy through stoma; with transendoscopic balloon dilation

0.00*

3.33

n/a

44406

Colonoscopy through stoma; with endoscopic ultrasound examination, limited to the sigmoid, descending, transverse, or ascending colon and cecum and adjacent structures

0.00*

4.20

n/a

44407

Colonoscopy through stoma; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s), includes endoscopic ultrasound examination limited to the sigmoid, descending, transverse, or ascending colon and cecum and adjacent structures

0.00*

5.06

n/a

44408

Colonoscopy through stoma; with decompression (for pathologic distention) (eg, volvulus, megacolon), including placement of decompression tube, when performed

0.00*

4.24

n/a

Sigmoidoscopy, flexible

45330

Sigmoidoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)

0.96

0.84

–13%

45331

Sigmoidoscopy, flexible; with biopsy, single or multiple

1.15

1.14

–1

45332

Sigmoidoscopy, flexible; with removal of foreign body(ies)

1.79

1.86

4

45333

Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps

1.79

1.65

–8

45334

Sigmoidoscopy, flexible; with control of bleeding, any method

2.73

2.10

–23

45335

Sigmoidoscopy, flexible; with directed submucosal injection(s), any substance

1.46

1.14

–22

45337

Sigmoidoscopy, flexible; with decompression (for pathologic distention) (eg, volvulus, megacolon), including placement of decompression tube, when performed

2.36

2.20

–7

45338

Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique

2.34

2.15

–8

45340

Sigmoidoscopy, flexible; with transendoscopic balloon dilation

1.89

1.35

–29

45341

Sigmoidoscopy, flexible; with endoscopic ultrasound examination

2.60

2.22

–15

45342

Sigmoidoscopy, flexible; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(ies)

4.05

3.08

–24

45346

Sigmoidoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed)

3.14

2.91

–7

45347

Sigmoidoscopy, flexible; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed)

2.92

2.82

–3

45349

Sigmoidoscopy, flexible; with endoscopic mucosal resection

0.00*

3.62

n/a

45350

Sigmoidoscopy, flexible; with band ligation(s) (eg, hemorrhoids)

0.00*

1.78

n/a

Colonoscopy, flexible

45378

Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)

3.69

3.36

–9

45378–53

Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)

0.96

1.68

75

45379

Colonoscopy, flexible; with removal of foreign body(s)

4.68

4.38

–6

45380

Colonoscopy, flexible; with biopsy, single or multiple

4.43

3.66

–17

45381

Colonoscopy, flexible; with directed submucosal injection(s), any substance

4.19

3.66

–13

45382

Colonoscopy, flexible; with control of bleeding, any method

5.68

4.76

–16

45384

Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps

4.69

4.17

–11

45385

Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique

5.30

4.67

–12

45386

Colonoscopy, flexible; with transendoscopic balloon dilation

4.57

3.87

–15

45388

Colonoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed)

5.86

4.98

–15

45389

Colonoscopy, flexible; with endoscopic stent placement (includes pre- and post-dilation and guide wire passage, when performed)

5.90

5.34

–9%

45390

Colonoscopy, flexible; with endoscopic mucosal resection

0.00*

6.14

n/a

45391

Colonoscopy, flexible; with endoscopic ultrasound examination limited to the rectum, sigmoid, descending, transverse, or ascending colon and cecum, and adjacent structures

5.09

4.74

–7

45392

Colonoscopy, flexible; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s), includes endoscopic ultrasound examination limited to the rectum, sigmoid, descending, transverse, or ascending colon and cecum, and adjacent structures

6.54

5.60

–14

45393

Colonoscopy, flexible; with decompression (for pathologic distention) (eg, volvulus, megacolon), including placement of decompression tube, when performed

0.00*

4.78

n/a

45398

Colonoscopy, flexible; with band ligation(s) (eg, hemorrhoids)

0.00*

4.30

n/a

Screening endoscopy

G0104

Colorectal cancer screening; flexible sigmoidoscopy

0.96

0.84

–13

G0105

Colorectal cancer screening; colonoscopy on individual at high risk

3.36

3.36

0

G0105–53

Colorectal cancer screening; colonoscopy on individual at high risk

0.96

1.68

75

G0121

Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk

3.36

3.36

0

G0121-53

Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk

0.96

1.68

75

*Reported with unlisted code and carrier priced for 2015.

The Colonoscopy Decision Tree (see Figure 1) is designed to assist with correct CPT code and modifier selection.

Figure 1. Colonoscopy Decision Tree

Colonoscopy Decision Tree

*Reprinted with permission, American Medical Association.

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.

Soft-tissue localization

Two new Category I codes were established to report initial and additional lesion placement of soft-tissue localization device(s), including imaging guidance. If a more specific site descriptor than “soft tissue” is applicable (for example, breast), the site-specific code for marker placement at that site should be reported. In addition, the new codes should only be reported once per target, regardless of how many markers (that is, clips, wires, pellets, and radioactive seeds) are used to mark that target. These new codes may be used to report placement of localization device(s) for axillary lymph nodes following biopsy and include the following (• = new code for 2016, + = add-on code):

  • 10035, Placement of soft tissue localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous, including imaging guidance; first lesion
  • +10036, each additional lesion (list separately in addition to code for primary procedure)

Open treatment of rib fracture without fixation

Code 21805, Open treatment of rib fracture without fixation, each, was deleted from the 2016 CPT code set and determined to be obsolete and reportable with other CPT codes. In current practice, an injured rib when treated in an open fashion is either resected (eg, 21600) or treated with some form of internal fixation (eg, codes 21811–21813). For more information on treatment of rib fractures code sets, refer to the January 2015 issue of the Bulletin.

Intravascular ultrasound

Two new Category I “add-on” codes were established to report noncoronary intravascular ultrasound (IVUS) during diagnostic evaluation and/or therapeutic intervention. In addition, codes 37250 and 37251 and related radiological supervision and interpretation codes 75945 and 75946 were deleted. All transducer manipulations and repositioning within the specific vessel examined during a diagnostic procedure or before, during, and/or after therapeutic intervention (such as stent or stent graft placement, angioplasty, atherectomy, embolization, thrombolysis, and transcatheter biopsy) is bundled into the IVUS codes and may not be reported separately. However, non-selective and/or selective vascular catheterization may be separately reportable (for example, codes 36005–36248). The two new IVUS Category I add-on codes include the following:

  • +37252, Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation; initial noncoronary vessel (List separately in addition to code for primary procedure)
  • +37253 each additional noncoronary vessel (List separately in addition to code for primary procedure)

Mediastinoscopy with biopsy

Two new CPT Category I codes (39401 and 39402) were established to replace code 39400, Mediastinoscopy, includes biopsy(ies), when performed. The new codes differentiate mediastinoscopy for biopsy of a mediastinal mass from lymph node biopsy(ies). Over the last 10 years, the number of mediastinoscopies performed has steadily declined. This decrease is attributable to the development and refinement of noninvasive lung cancer staging modalities such as computed tomography (CT) and positron emission tomography (PET). Additionally, pathologic staging of lung cancer can now be done using the less invasive technique of endoscopic bronchoscopic ultrasound (EBUS)-guided biopsy. Mediastinoscopy is most commonly performed for the staging of lung cancer and is used only when the previously mentioned modalities are inconclusive. It also is performed in patients deemed to be high risk for lung surgery (such as patients with chronic obstructive pulmonary disease). While the proper staging of lung cancer, which may involve the systematic biopsying of designated lymph node stations, is critical for determining appropriate treatment, mediastinoscopy can also be used to establish a diagnosis in patients with a large mediastinal mass. These are distinctly different patient populations. The two new codes allow for more accurate reporting of the different procedures and patient populations. These two new mediastinoscopy with biopsy codes include the following:

  • 39401, Mediastinoscopy; includes biopsy(ies) of mediastinal mass (eg, lymphoma), when performed
  • 39402, with lymph node biopsy(ies) (eg, lung cancer staging)

Heterotopic liver transplantation

Code 47136, Liver allotransplantation; heterotopic, partial or whole, from cadaver or living donor, any age was deleted from the 2016 CPT code set. This procedure (also known as auxiliary liver transplantation) involved leaving the recipient organ in place while transplanting a donor liver in a different (ectopic) location. When introduced, heterotopic liver allotransplantation was believed to be useful for reversible liver disease whereby the transplanted liver could be removed once the native liver recovered. However, this technique has been associated with increased surgical complications and is unsuitable for liver diseases where the native liver is at risk of further disease. The procedure is rarely performed in the U.S. and therefore was deleted. A reference was added to use 47399, Unlisted procedure, liver to report this procedure.

Laparoscopic transhepatic cholangiography

Codes 47560, Laparoscopy, surgical; with guided transhepatic cholangiography, without biopsy and 47561, Laparoscopy, surgical; with guided transhepatic cholangiography with biopsy were deleted from the 2016 CPT code set. These codes were developed prior to 1990 to report cholangiography using a laparoscope in jaundiced patients with diagnoses that remained obscure despite complete clinical, laboratory, and X ray evaluation. In the absence of laparoscopic examination, the next logical step in the diagnostic workup would have been laparotomy. With advances in imaging (including magnetic resonance imaging and CT) and technology (including percutaneous transhepatic cholangiography), laparoscopic transhepatic cholangiography is no longer standard practice.

Esophageal sphincter augmentation

Two new Category III codes were established to report insertion and removal of a magnetic bead band on the esophageal sphincter for treatment of gastroesophageal reflux disease. Note that code 0392T reporting is restricted to placement of a magnetic band. In addition, placement of an esophageal sphincter augmentation device should not be reported at the same time as any other fundoplication procedure. The new codes include the following:

  • 0392T, Laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device (ie, magnetic band)
  • 0393T, Removal of esophageal sphincter augmentation device

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 codes and descriptions are © 2015 American Medical Association. All rights reserved. CPT and CodeManager are registered trademarks of the American Medical Association.

Barney L, Savarise MT. 2015 CPT coding changes will have mixed effects on payment for general surgeons. Bull Am Coll Surg. 2015;100(1):17-26.

 

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