By Kim Huey, MJ, CHC, CPC, CCS-P, PCS, CPCO, COC
The American Medical Association (AMA) released changes for the CPT code set in 2020 that include 248 new codes, 75 revised codes, and 71 deleted codes. The numbers do not tell the whole story, however, as guideline changes for existing codes represent some of the most significant and pervasive changes.
Modifier 50 is not to be used on add-on codes per new CPT guidance; instead, the number of units will be assigned. For example, if a physician performs bilateral paravertebral facet joint injections at two levels, the correct coding would be 64493-50 for the first level and add-on code 64494 times two units for the second level.
Evaluation and Management updates include changes to the codes for Online Digital Evaluation and Management Services. The AMA specified that these services must be patient-initiated and that they require a clinical decision that would otherwise be made during an office visit. Three codes represent differing amounts of time:
- Code 99421 for 5–10 minutes
- Code 99422 for 11–20 minutes
- Code 99423 for 21 or more minutes
Less than five minutes is not reportable. Time is calculated based on the total time spent evaluating and responding to the patient’s issue over a seven-day period. The service is not billable if the patient is seen either through telehealth or in a face-to-face visit during the seven-day period. Only the time spent by a physician or other qualified healthcare professional (QHP)—a professional who is qualified through education, state licensure, and facility privileging to perform a service and who is allowed to independently report that service—may be counted.1 Similar codes were established in the Medicine Section for these services provided by nonphysician healthcare professionals such as physical therapists, social workers, and dieticians. The same guidelines and time specifications apply to the nonphysician codes 98970, 98971, and 98972 and to the physician codes 99421, 99422, and 99423.
Remote physiologic monitoring code 99457 is revised to specify the first 20 minutes in the calendar month, with the new code 99458 as an add-on code for each additional 20 minutes.
When a patient’s blood pressure is elevated at an office visit, it is common for the physician to ask the patient to measure their blood pressure at home over a period of time before a diagnosis and treatment plan is established. This has always been considered part of whatever face-to-face services are performed; however, the 2020 update to CPT provides codes to report these services. Code 99473 will be reported when clinical staff educate the patient on proper use of the blood pressure monitor. Code 99473 accounts for the physician work of reviewing the patient log, establishing the treatment plan, and communicating that plan to the patient. The intent is for the patient to self-measure their blood pressure with two readings one minute apart twice daily; however, the physician may report this code with a review of at least 12 readings.
Changes in the Integumentary System include revisions to the Repair guidelines. The 2020 update clarifies what criteria must be met to support complex repair versus intermediate repair. Complex repair requires documentation of at least one of the following:
- Exposure of bone, cartilage, tendon, or named neurovascular structure
- Debridement of wound edges (e.g., traumatic lacerations or avulsions)
- Extensive undermining
- Involvement of free margins of helical rim, vermilion border, or nostril rim
- Placement of retention sutures
Extensive undermining is defined as a distance greater than or equal to the maximum width of the defect, measured perpendicular to the closure line along at least one entire edge of the defect. Physicians will be required to document measurements of the undermining along with the measurement of the defect and repair.
New codes have been established for grafting of autologous soft tissue, both when harvested by direct excision or by liposuction. Liposuction codes 15771–15774 are based on the recipient site and the amount of injectate.
Revisions to the breast procedure codes include a clarification that mastectomy codes, other than the code for mastectomy for gynecomastia, may only be reported when performed to treat or prevent breast cancer. CPT code 19304 for subcutaneous mastectomy was deleted as that is a surgical technique that is no longer used very often. Codes for excision of chest wall tumor were moved to the Musculoskeletal System, with no change in the code definitions.
Similar to trigger point injections, “dry needling” involves insertion of a needle into a point in a muscle but without injection of a medication. Prior to the 2020 update, these services were billed with unlisted codes. CPT code 20560 is used to report needle insertion into one or two muscles; code 20561 is to report when insertion is performed into three or more muscles.
New add-on codes were established to report manual preparation and insertion of a drug delivery device during an orthopedic procedure, such as incision and drainage of a muscle or revision arthroplasty. These codes are not to be reported when the surgeon uses an “off-the-shelf” device; rather, they require the preparation and insertion of the device, such as antibiotic beads. Insertion without preparation will not be reported separately from whatever primary procedure is performed. If removal of the device is performed as the sole procedure at that operative session, existing code 20680 for removal of deep implant is assigned.
Due to changes in clinical practice in performing pericardiocentesis, existing codes 33011 and 33015 have been deleted and new codes 33016-33019 were created. Code selection will be dependent on whether the catheter is left in place at the conclusion of the procedure. A different code, 33018, is available for patients under the age of five or for any patient with congenital cardiac anomaly, regardless of the patient’s age. New codes were created for aortic arch graft to reflect the reason for the graft—aortic dissection versus aneurysm—because a dissection would require an emergent procedure with significantly different work than an aneurysm. Existing CPT code 33870 for transverse aortic arch graft was replaced by the new code 33871 to more specifically describe the work involved, including the required reimplantation of the arch vessels.
There are two new codes for a branched iliac artery endograft when a patient requires treatment of the iliac artery in addition to an aorto-iliac endograft. CPT code 34717 is an add-on code when the graft is placed at the same operative session as the aortoiliac endograft. CPT code 34718 is a standalone code when the procedure is performed at a separate operative session. These codes represent unilateral procedures. If both iliac arteries are treated, code 34718 would be reported with modifier 50, while code 34717 would be reported with two units of service.
Changes have been made to the codes for exploration of an artery, collapsing the existing codes into only three. Codes are no longer indicative of a specific artery (e.g., carotid, femoral, popliteal), but rather a general body area such as neck for code 35701, upper extremity for code 35702, and lower extremity for code 35703.
A new anoscopic treatment procedure for hemorrhoids required a new CPT code to represent the unique work involved. Code 46948 for transanal hemorrhoidal dearterialization represents ligation of the superior rectal artery rather than the traditional excision of the hemorrhoidal bundle. This code requires treatment of two or more hemorrhoid columns, as one column is not treated in this manner. New code for preperitoneal packing for pelvic trauma represents the initial exploration and packing (code 49013) and re-exploration (code 49014).
Two new lumbar puncture codes were added to report procedures when they are performed under fluoroscopic or CT guidance. According to the Relative Value Update Relativity Assessment Workgroup, these services have been reported more often by Radiology and are reported with guidance more than 50 percent of the time. CPT code 62328 is reported when the procedure is diagnostic in nature, while code 62329 is reported when the procedure is performed to drain cerebrospinal fluid. Existing codes remain for use when the procedure is performed without guidance or under the less common ultrasound or MR guidance.
The descriptions associated with the somatic nerve injections, 64400–64450, were revised to specify that these codes are to be reported once per nerve regardless of the number of injections and that imaging guidance may be reported separately. These codes were also restructured to reflect the parent/child coding concept common in CPT; code 64400 is the “parent code,” where the code descriptor establishes the language common to the child codes indented underneath. New codes include:
- Code 64451 for injection of the nerves innervating the sacroiliac joint
- Code 64454 for the genicular nerve branches
Code 64451 requires the use of imaging guidance, while 64454 includes imaging guidance when performed. Codes were also established for destruction of the genicular nerve branches (64624) and radiofrequency ablation of the nerves innervating the sacroiliac joint (64625).
It has become common for cyclophotocoagulation—laser treatment to reduce intraocular pressure—to be performed at the same session as cataract removal. New codes 66987 and 66988 were created to report those instances, and 66711 was revised to be used when cataract surgery is not performed at the same session.
Changes in Radiology coding for 2020 include new codes for double-contrast upper gastrointestinal (GI) studies and revised descriptions for other upper and lower GI codes to specify that scout images and delayed images are included in the existing codes. CPT codes for myocardial positron emission tomography (PET) studies were revised and new codes established to report when PET and CT are performed concurrently. Revisions were made in the SPECT-CT section (single-photon emission computerized tomography) to employ a generic coding approach. Codes for specific organs were deleted as the work involved was the same, regardless of the specific organ. Codes now reflect planar, or two-dimensional imaging, versus SPECT, which is three-dimensional imaging.
Changes in Pathology and Laboratory coding for 2020 include six new codes for therapeutic drug assays, three new codes for Multianalyte Assays with Algorithmic Analyses (MAAA), and one new microbiology code for mycoplasma genitalium. In Molecular Pathology, several codes were moved from Tier 2 to Tier 1 and vice versa. The Proprietary Laboratory Analyses (PLA) codes continue to expand with 75 new codes for 2020. The PLA codes were established by the Protecting Access to Medicare Act of 2014. These codes are not required to fulfill the Category I criteria, but the test each represents must be commercially available in the United States for use on human specimens. The manufacturer or clinical laboratory must request the code.
One of the most significant changes, in terms of the number of codes and extent of coding guidelines, is for Long-term EEG Monitoring. These services represent electroencephalography monitoring of two hours or longer. The codes have been separated into those for reporting professional versus technical services. Professional codes 95717–95726 are based on whether video recording is performed, the duration of the monitoring, and at what point the report is completed.
Technical component codes are determined by the use of video recording and the duration and intensity of the monitoring services. CPT also specifies that monitoring must be performed by an EEG technologist who is qualified by education, training, and licensure/certification/regulation (when applicable) in seizure recognition. Services may be continuously monitored, intermittently monitored, or unmonitored. Continuous monitoring may be remote or onsite and is considered the monitoring of no more than four patients with no break in monitoring. Likewise, intermittent monitoring may be remote or onsite but involves the monitoring of no more than 12 patients. A study in which the monitoring does not meet either of these criteria is considered unmonitored. Page 715 of the CPT 2020 Professional Edition includes a table delineating these requirements.
Other changes in the Medicine section include two new vaccine codes:
- Code 90694 for Influenza virus vaccine, quadrivalent (aIIV4), inactivated, adjuvanted, preservative free, 0.5-mL dosage, for intramuscular use
- Code 90619 for Meningococcal conjugate vaccine, serogroups A, C, W, Y, quadrivalent, tetanus toxoid carrier (MenACWY-TT), for intramuscular use
As of press time, both of these vaccines are awaiting FDA approval and therefore carry the lightning bolt symbol. Codes for biofeedback training for perineal muscles were updated to reflect the time intensity of this service. CPT codes 92201–92202 are new for ophthalmoscopy for retinal drawing or drawing of the optic nerve. This is commonly performed in addition to retinal photography, but only one service may be reported.
A new add-on code, 93356, was created to be used in conjunction with echocardiography when myocardial strain imaging is performed. Myocardial strain refers to the change in the myocardium through the cardiac cycle and may indicate sub-clinical impairment of the heart before the development of symptoms and irreversible damage.
There are 51 new Category III codes for new technology. These codes are tracked to determine efficacy of the treatment described and whether the use of such technology is widespread enough to warrant issuance of a Category I code. Services represented in this category include transapical mitral valve repair, islet cell transplantation, and continence device procedures as well as two new procedures that may potentially replace DEXA scans in more accurately measuring bone density.
You can see that the changes in CPT for 2020 highlight the necessity of reviewing and understanding the guidelines associated with each code, not just understanding the specific new, revised, and deleted codes themselves.
- American Medical Association. AMA CPT Professional 2020. Chicago: 2019, page xiii.
American Medical Association. CPT Changes 2020: An Insider’s View. Chicago: 2020.
Kim Huey (firstname.lastname@example.org) is consultant at KGG Coding and Reimbursement Consulting, LLC.
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