By Leigh Poland, RHIA, CCS
On September 1, 2020, the American Medical Association (AMA) released the 2021 Current Procedural Terminology (CPT) code set, which became effective January 1. This year, the AMA did not disappoint with the number of changes or the significance of these changes. There are a total of 329 CPT code changes for 2021, including 206 code additions, 54 code deletions, and 69 code revisions. The graph below shows a summary of the changes for each CPT code section. This article reviews the key changes for 2021 by CPT code section.
|Breakdown of 2021 CPT Code Set Changes|
|Evaluation and Management Services||2||1||17|
|Pathology and Laboratory Procedures||43||1||9|
|Medicine Services and Procedures||18||9||4|
|Category II Codes||0||0||1|
|Category III Codes||45||23||1|
Evaluation and Management
For years there’s been a lot of discussion among the AMA, coding professionals, and other industry leaders about the need to make changes to the Evaluation and Management (E/M) guidelines and codes. According to the AMA press release regarding the 2021 CPT code updates, the office and other E/M services codes and guidelines received its “first major overhaul in more than 25 years.”
E/M codes for provider offices and other outpatient services are still divided into new patient services (99202-99205) and established patient services (99211-99215). Key changes to note for the office and other E/M services codes (99202-99215) and guidelines include:
- Code 99201 has been deleted and parenthetical notes state to use code 99202 instead.
- Code descriptions were changed for office or outpatient service E/M codes 99202-99215.
- For office visits, the history and examination terminology has been removed from the code description and replaced with the terms “medically appropriate history and/or exam.” There also are new time thresholds assigned to each CPT code description.
- For office visits, the E/M guidelines state coders may select the appropriate level of E/M service by using either the medical decision-making (MDM) table or total time on the date of the encounter.
- There is a new MDM table to calculate the MDM level of service. The elements that outline each of the four MDM levels are different. Key differences for office and outpatient visits include:
- The complexity and number of problems addressed in the visit
- The complexity and amount of data to be reviewed
- Risk of complications or morbidity of patient management
- The guidelines now state time of encounter as the total time of the encounter, not 51 percent or more of the encounter. The time must be clearly documented in the medical record for the coder to be able to use time alone to calculate the levels.
The E/M services section also includes a new add-on code for prolonged services. Code 99417 is to be used for “prolonged office or other outpatient E/M services beyond the minimum time of the primary procedure.” Parenthetical guidance for 99417 states to use the add-on code in conjunction with 99205 (75 minutes) and 99215 (55 minutes) and cannot be used for any time unit less than 15 minutes.
Coders who are responsible for assigning codes 99201-99215 should be sure to review all CPT guideline updates, new parenthetical notes, and updated code descriptions and make sure all coders, physicians, and applicable staff are ready for these key code changes and documentation requirements.
Integumentary System-Breast Repair and/or Reconstruction. For 2021, there were 15 codes revised and two codes deleted (19324 and 19366) in the breast repair and/or reconstruction subsection (19316-19499) of the Integumentary System section. Coders also will find new instructional guidance for each code and new introductory guidelines in this subsection. The new guidelines give detailed descriptions of the types of reconstruction used to repair defects using various techniques including latissimus dorsi flap; free flap (e.g., DIEP, fTRAM, SIEA, and GAP flap); and single or bipedicled transverse rectus abdominis myocutaneous (TRAM) flap.
The guidelines also clarify if different reconstruction procedures are performed on each breast. The code descriptions have been revised: the term mammary was replaced with the term breast and now includes language to indicate if the breast implant insertion was performed on the same day or on a separate day as the mastectomy.
Respiratory System—Nose. Code 30468 is new and was created to describe the repair of a nasal valve collapse with subcutaneous or submucosal lateral wall implants. A code was needed to identify opening the nasal collapse via minimally invasive techniques and utilizing absorbable lateral wall implants. Parenthetical guidance for code 30468 notes that this code is to be used to report a bilateral procedure. If the procedure is performed unilaterally, add modifier 52.
Respiratory System—Lungs and Pleura. Code 32408 was created for 2021 to report core needle biopsy of the lung or mediastinum using all types of imaging guidance including, but not limited to, CT, MRI, ultrasound, and fluoroscopy. The new guidelines for 32408 state that imaging guidance is not to be reported separately and the code is only used once per lesion sampled in a single session. If multiple lesions are sampled on the same day, assign 32408 for each lesion sampled along with modifier 59.
Cardiovascular System—Cardiac Assist. For 2021, two new CPT codes (33995 and 33997) and four revised CPT codes (33990-33993) reflect insertion, removal, and repositioning of right and left percutaneous ventricular assist devices (VADs). The revised codes for left heart insertion and revision specify if this procedure is performed via arterial access only or with both arterial and venous access. Additionally, cardiac assist guidelines were revised to indicate the changes made to this section of codes.
Male Genital System—Prostate. Code 55880 was added to report transrectal, high intensity-focused ultrasound (HIFU) guided ablation of malignant prostate tissue. Prior to 2021, coders were using an unlisted code to report this procedure.
Female Genital System—Cervix Uteri. Code57465 is a new add-on code created to report computer-aided colposcopy to aid in the biopsy of the cervix. Code 57465 is only to be used in conjunction with vaginal colposcopy procedures (57420, 57421) and cervical colposcopy procedures (57452-57461). The 57465 description states that it includes optical dynamic spectral imaging that aids in the mapping of abnormal areas for biopsy.
Auditory System—Other Procedures. New codes were created for dilation of the eustachian tube using nasopharyngoscopy technique. This procedure is commonly referred to as eustachian tube balloon dilation (ETBD). Prior to 2021, coders were using unlisted code 69799 to report this procedure, since there was not a specific code available. The descriptions indicate that 69705 is for unilateral dilation and 69706 is for bilateral dilation.
Diagnostic Radiology—Chest. Prior to 2021, there was not a code to specify a computed tomography (CT) scan for lung cancer screening. For 2021, new code 71271 was created to report a new low-dose CT scan for lung cancer screening. Codes 71250, 71260, and 71270 were revised to include the terminology “diagnostic,” since these codes are now to be used for diagnostic examination and not to screen an asymptomatic patient. The parenthetical guidance for code 71271 specifically notes this is not for breast CT procedures.
Audiologic Function Test-Auditory Evoked Potentials (AEP). This family of codes had not been reviewed since 1996, and clarification was needed “to better distinguish between the different types and levels of testing available.”
In response to this review, four new CPT codes were added to the audiologic function test family of codes (92650-92653) and two codes have been deleted (92585 and 92586). New parent code 92650 captures the work of a newborn hearing screen. There are three new child codes:
- Child code 92651 captures post-screening follow-up for AEP.
- Child code 92652 captures extensive electrophysiologic estimation of behavioral hearing thresholds.
- Child code 92653 was added to report neurodiagnostic assessment using AEP response to evaluate neural conduction.
Cardiovascular Monitoring Services-External Electrocardiographic (ECG) Reporting. There was a conversion of eight Category III codes (0295T-0298T) to Category I codes (93241-93248) to describe external ECG recording. Also, new guidelines and parenthetical notes have been added and existing guidelines have been revised in the cardiovascular monitoring section. New codes 93241-93244 are used to report external ECG for more than 48 hours and up to seven days. New codes 93245-93248 are used to report external ECG of more than seven days and up to 15 days.
Category III Codes
Category III codes are a set of temporary codes to capture emerging procedures, services, and technology and service paradigms. Forty-five new codes were added to this section for 2021. It is always interesting to review these emerging services. A few of the key notable changes for Category III include:
- Three new codes (0604T to 0606T) were created to report patient-initiated remote optical coherence tomograph (OCT) of the retina. This emerging technology is used for detection of neovascular disease activity
- Four new codes (0609T to 0612T) have been established to describe the localization of back pain using magnetic resonance (MR) spectroscopy and computer related transmission, postprocessing, and interpretation and report
- Six new codes (0633T to 0638T) were created to report three-dimensional (3D) rendering used for CT of the breast. This new procedure enhances visualization of pathology
It is the responsibility of coding professionals to keep up to date with these code changes and understand how to apply them beginning with January 1, 2021, discharges/dates of service.
It is a best practice for coders to review the guideline and code changes in their entirety and make sure all applicable team members including coders, physicians, and documentation specialists are educated regarding the code and documentation requirements.
American Medical Association. CPT Changes 2021: An Insider’s View: eBook. American Medical Association: 2021.
American Medical Association. CPT 2021 Professional Edition. American Medical Association: 2021.
American Medical Association. “AMA releases 2021 CPT code set.” September 1, 2021. https://www.ama-assn.org/press-center/press-releases/ama-releases-2021-cpt-code-set.
Robeznieks, Andis. “How 2021 E/M coding changes will reshape the physician note.” November 6, 2020. https://www.ama-assn.org/practice-management/cpt/how-2021-em-coding-changes-will-reshape-physician-note.
Leigh Poland (Leigh.firstname.lastname@example.org) is executive director of education at AGS Health.