Numerous changes in Current Procedural Terminology (CPT)* coding will be implemented in 2020. This article provides reporting information about the codes that are relevant to general surgery and its related specialties.
Revision of guidelines for repair (closure)
The introductory guidelines in the CPT Integumentary System, Repair (Closure) subsection have been revised to provide more descriptive language to clarify that intermediate repair includes limited undermining. The guidelines also clarify that complex repair includes all the requirements listed for intermediate repair plus at least one of the following: exposure of bone, cartilage, tendon, or named neurovascular structure; debridement of wound edges; extensive undermining; involvement of free margins of the helical rim, vermillion border, or nostril rim; or placement of retention sutures. References to stents and scar revision have been removed from the complex repair guidelines. The guidelines also will include a definition and an illustration (see Figure 1) of extensive undermining. Please refer to the CPT code book for detailed definitions of intermediate and complex repair.
Figure 1. Extensive undermining
New graft codes
The American Medical Association (AMA) Specialty Relative Value Scale (RVS) Update Committee (RUC) identified code 20926, Tissue grafts, other (eg, paratenon, fat, dermis), as potentially misvalued. The stakeholder societies determined that this code represented many different types of tissue grafts that required different physician work. For 2020, code 20926 will be deleted and replaced with five new codes (15769–15774) in the Integumentary System, Other Flaps and Grafts subsection. Table 1 provides the new code descriptors and relative value units (RVUs) for 2020.
Table 1. Integumentary system, other flaps and grafts
The “Incision” and “Excision” subheadings will be deleted from the CPT Integumentary System, Breast subsection. The guidelines preceding the breast biopsy codes (previously under the deleted “Excision” subheading) have been extensively revised, including the addition of clear instructions for reporting percutaneous and image-guided breast biopsy, open incisional breast biopsy, and open excision of a breast lesion. Similarly, the guidelines under the “Breast, Introduction” subheading have been extensively revised to provide clear instructions for reporting percutaneous image-guided placement of breast localization device(s). Instructions also have been added for correct reporting of bilateral procedures, and new introductory text has been added to the Breast, Mastectomy Procedures subsection that describes and differentiates mastectomy procedures.
Nipple- and skin-sparing mastectomy
In 2017, the CPT Assistant Editorial Board requested clarification for coding nipple- and skin-sparing mastectomy procedures. Upon review, the stakeholder specialties determined that code 19304, Mastectomy, subcutaneous, has been misreported for a mastectomy procedure that included a nipple- or skin-sparing technique, which should have correctly been reported as a mastectomy procedure using code 19303, Mastectomy, simple, complete. A subcutaneous mastectomy (that is, removing some breast tissue) is a technique introduced in the 1960s that is no longer standard of care; therefore, code 19304 will be deleted for 2020.
New instructional parentheticals were added to direct reporting code 19300, Mastectomy for gynecomastia, for breast tissue removed for breast reduction for gynecomastia and code 19318, Reduction mammaplasty, for breast tissue removed for breast size reduction for other than gynecomastia.
Chest wall procedures
Stakeholder specialties determined that codes 19260, 19271, and 19272, which describe the radical resection of a chest wall tumor involving and/or including rib(s), were misplaced in the Integumentary System, Breast subsection. As a result of this review, these codes were renumbered 21601–21603 and relocated to the Musculoskeletal System, Neck (Soft Tissues) and Thorax subsection.
Exploration of artery without repair
Changes have been made to the artery exploration family of codes in the Cardiovascular System, Arteries and Veins subsection. One code (35701) has been revised, two new codes (35702, 35703) have been added, and three codes (35721, 35741, 35761) have been deleted. Prior to CPT 2020, the code descriptors for exploration of artery included the language “with or without lysis of artery.” Since lysis of the artery during exploration rarely is performed, this language has been removed from the code descriptors. The revised code and new codes continue to indicate that an artery is explored and “not followed by surgical repair.” Existing code 35701 has been revised to describe exploration of artery in the neck. New code 35702 was established to report exploration of an upper extremity artery and new code 35703 was established to report exploration of a lower extremity artery. The code descriptors include examples of typical arteries. Codes 35721 (exploration of femoral artery) and 35741 (exploration of popliteal artery) were deleted with directions to report exploration of a lower extremity artery with code 35703. Code 35761 (exploration of other artery) was deleted with directions to use 37799 to report vascular exploration not followed by surgical repair, other than neck artery, upper extremity artery, lower extremity artery, chest, abdomen, or retroperitoneal area.
When artery exploration is performed on the same side of the neck as blood vessel repair; exploration for postoperative hemorrhage, thrombosis, or infection; or flap or graft procedures in the neck, code 35701 may not be reported separately. When artery exploration is performed on the same extremity as blood vessel repair, code 35702 or 35703 may not be reported separately. Importantly, codes 35701, 35702, and 35703 may only be reported with a surgical procedure performed by the same surgeon if the other procedure is a nonvascular surgical procedure and the artery exploration is performed through a separate incision. Table 2 provides the new and revised code descriptors and RVUs for 2020.
Table 2. Exploration of artery
Transanal hemorrhoidal dearterialization (THD)
CPT Category III code 0249T, Ligation, hemorrhoidal vascular bundle(s), including ultrasound guidance, has been deleted and converted to CPT Category I code 46948, Hemorrhoidectomy, internal, by transanal hemorrhoidal dearterialization, 2 or more hemorrhoid columns/groups, including ultrasound guidance, with mucopexy, when performed. THD is a nonexcisional surgical technique developed for the treatment of internal hemorrhoids. This technique is based on the identification and ligation of the terminal branches of the superior rectal artery through a specially developed anoscope equipped with an ultrasound probe that allows localization of arteries that are individually ligated as needed to interrupt hemorrhoid blood supply. When required, a ring of sutures also will be deployed to pull up a prolapse (mucopexy). Family codes 46945 and 46946 were revised to differentiate the work from new code 46948. Separately, all parenthetical references to deleted code 0249T also will be revised. New code 46948 indicates that at least two columns/groups must be treated to report this code. If only one column/group is treated, then code 46999, Unlisted procedure, anus, should be reported. Table 3 provides the new and revised code descriptors and RVUs for 2020.
Table 3. Hemorrhoidectomy
Radiofrequency spectroscopy at time of mastectomy
New CPT Category III code 0546T, Radiofrequency spectroscopy, real time, intraoperative margin assessment, at the time of partial mastectomy, with report, may only be reported with codes 19301 or 19302 (partial mastectomy) and only once for each partial mastectomy site. Code 0546T may not be reported for re-excision. The term “with report” indicates that a written report (for example, handwritten or electronic) signed by the interpreting individual is required. CPT Category III codes do not have assigned RVUs and are considered emerging or evolving procedures or services. CPT Category III code eligibility for payment, as well as coverage policy, is determined by each individual third-party payor. For specific details about payment for this procedure, physicians should contact their local third-party payors because reimbursement varies.
Cryoablation of malignant breast tumors
Cryoablation of malignant breast tumor(s) will now be reported with a new code, 0581T, Ablation, malignant breast tumor(s), percutaneous, cryotherapy, including imaging guidance when performed, unilateral. Physicians should continue to report cryoablation of “fibroadenomas” with code 19105, Ablation, cryosurgical, of fibroadenoma, including ultrasound guidance, each fibroadenoma. Note that code 0581T includes any imaging modality for guidance, whereas code 19105 only includes ultrasound guidance. In addition, code 0581T may be reported only once per breast treated no matter how many tumors are ablated, whereas code 19105 should be reported for each fibroadenoma ablated. CPT Category III code eligibility for payment, as well as coverage policy, is determined by each individual third-party payor. Physicians should contact their local third-party payors for specific reimbursement policies.
Preperitoneal pelvic packing
The Military Health System Strategic Partnership American College of Surgeons (MHSSPACS) was established in 2014 to improve educational opportunities, inform systems-based practices, and drive surgical research capabilities. Although some trauma injuries are uncommon in the U.S., members of the MHSSPACS U.S. military medical personnel use CPT codes to indicate work performed at military bases and on the battlefield around the world. These procedures also may be performed for battle wound-type injuries, such as the pelvic damage that runners and bystanders sustained at the Boston Marathon in 2013 when angioembolization services were unavailable or inaccessible in a timely manner for all patients needing immediate treatment.
For CPT 2020, a new CPT Category I code (49013) was approved to report preperitoneal pelvic packing without a laparotomy. A second code (49014) was approved for packing removal that will occur on a subsequent day. These two new codes differ from other exploratory procedures in that a laparotomy is not performed. Instead, a Pfannenstiel low horizontal incision is made just above the pubic rim, with dissection carried out until the urinary bladder is identified, without opening the peritoneum. Table 4 provides the new code descriptors and RVUs for 2020.
Table 4. Preperitoneal pelvic packing
Code 54640 is a CPT legacy code (pre-1990). The inclusion of “with or without” terminology in the code descriptor did not mean “includes when performed.” This verbiage was clarified with the addition of a parenthetical note in 2001 that stated, “For inguinal hernia repair performed in conjunction with inguinal orchiopexy, see 49495–49525.” The AMA CPT 2001 Changes publication provided the following rationale for the revision: “To allay misinterpretation that inguinal hernia repair is an inclusive procedure of the orchiopexy code 54640, a cross-reference was added directing users to the appropriate hernia repair code (49495–49525). When an inguinal hernia repair is performed in addition to an orchiopexy, both code 54640 and the appropriate inguinal hernia repair code 49495–49525, should be reported.” However, coding confusion developed after an erroneous CPT Assistant was published in 2008, and further coding changes were necessary. For CPT 2020, the code descriptor has been revised. Although the revision was editorial, the AMA RUC required review of physician work. Table 5 provides the updated code descriptor and RVUs for 2020.
Table 5. Orchiopexy
Vessel assessment prior to creation of hemodialysis access
In 2005, CMS created Healthcare Common Procedure Coding System (HCPCS) code G0365, Vessel mapping of vessels for hemodialysis access (services for preoperative vessel mapping prior to creation of hemodialysis access using an autogenous hemodialysis conduit, including arterial inflow and venous outflow), to report venous mapping for hemodialysis access placement to allow tracking of venous mapping for quality improvement purposes and to analyze the relationship between venous mapping utilization and fistula formation. The AMA RUC identified code G0365 as potentially misvalued because it never was reviewed for physician work and had Medicare utilization greater than 30,000. The stakeholder specialties agreed to create CPT Category I codes to replace this HCPCS code. For CPT 2020, two new CPT Category I codes will be available to report a duplex scan of arterial inflow and venous outflow for preoperative vessel assessment prior to creation of hemodialysis access. Code 93985 describes a complete bilateral study and code 93986 describes a unilateral study. In addition to creating the two new codes, new subsection guidelines will be added to the codebook to instruct users when to report the new codes or other related codes depending on the type of vessel study performed. New parenthetical notes further instruct users on the restrictions of reporting related vessel study codes on the same extremity. Table 6 provides the new code descriptors and RVUs for 2020.
Table 6. Vessel assessment for hemodialysis access
The expansion of electronic health record use with associated Health Insurance Portability and Accountability Act (HIPAA)-compliant patient portals has resulted in the creation of three new online digital evaluation and management (E/M) codes—sometimes referred to as an eVisit. Codes 99421–99423 are reported once for the physician’s or other qualified health care professional’s cumulative time devoted to the digital E/M service during a seven-day period. This codeset includes significant restrictions and instructions for correct reporting. The patient must be an established patient, although the problem may be new. The patient must initiate the eVisit, and communication platforms must comply with HIPAA. These codes may not be reported if a separately reported E/M visit occurs within seven days of the first day of patient inquiry. Refer to the CPT code book for detailed guidelines and coding instructions. Table 7 provides the new code descriptors and RVUs for 2020.
Table 7. eVisit
Deletion of rarely used or outmoded procedure codes
The AMA CPT Editorial Panel annually screens the codeset for codes that are rarely or never used. Stakeholder societies and manufacturers are able to provide a rationale for maintaining the code. For CPT 2020, code 43401, Transection of esophagus with repair, for esophageal varices, will be deleted as it is no longer standard practice. Code 0377T, Anoscopy with directed submucosal injection of bulking agent for fecal incontinence, also will be deleted because no party expressed an interest in maintaining it.
Learn more about correct coding at an ACS General Surgery Coding Workshop. Physicians receive up to 6.5 AMA PRA Category 1 Credits™ for each day of participation.
The ACS will offer the following workshops in 2020:
- Las Vegas, NV, January 30–31
- Dallas, TX, March 19–20
- Nashville, TN, August 6–8 (third day focuses on trauma)
- Chicago, IL, November 12–14 (third day focuses on trauma)
For more information about the 2020 ACS General Surgery Coding Workshops, visit the ACS website.
*All specific references to CPT codes and descriptions are © 2018 American Medical Association. All rights reserved. CPT and CodeManager are registered trademarks of the American Medical Association.