Part 5 – New 2019 CPT Codes: Category III, Evaluation and Management, etc.
RHIA, CDIP, CCS, CCS‑P, CIRCC
Executive Director Of Education
AHIMA‑Approved ICD‑10‑CM/PCS Trainer and Ambassador
This is Part 5 of a five part series on the new 2019 CPT codes. In this series we will explore the CPT changes for FY 2019 and include examples to help the coder understand the new codes. For the remaining areas we will just briefly summarize the section. Due to the intricate nature of these sections in CPT, it is recommended that the coder read the entire section notes associated with the new codes.
Category III Codes
Category III CPT codes are released semi-annually, in January and July. There are 38 new, 29 deleted and 3 revised Category III codes. Review pages 764-789 of CPT book which indicate the new codes delineated by a red circle. Many of the Category III codes not discussed in the previous 4 parts of this series involve more diagnostic and testing procedures across all specialties. Of note is a new “Cellular and Gene Therapy” subsection. This subsection includes codes 0533T-0536T Continuous recording of movement disorder symptoms and 0537T-0542T Chimeric antigen receptor T-cell (CAR-T) therapy.
Use Category III codes first before regular surgical CPT codes.
For radiology there are 10 new codes, 6 deleted, and 4 revised. There are 6 new ultrasound and ultrasound with elastography codes scattered throughout the chapter (76391, 76978-76979, 76981-76983). Transient elastography gives a quantitative one-dimensional (i.e. a line) image of tissue stiffness. It functions by vibrating the skin with a motor to create a passing distortion in the tissue (a shear wave), and imaging the motion of that distortion as it passes deeper into the body using a 1D ultrasound beam.
There are 4 new magnetic resonance imaging of breast codes, 77046-77049. These codes now denote if without contrast or without and with contrast materials including CAD to reflect current practice. Old codes 77058,77059 have been deleted.
For this section there are 29 new codes, 13 deleted, and 17 revised Medicine CPT Codes.
1 new code 93264, is for remote monitoring of wireless pulmonary artery pressure sensor.
There are 7 new or revised neurostimulator monitoring codes. There is a new “Adaptive Behaviour Services – Assessments – Treatment” subsections and other CNS testing.
Laboratory and Pathology
There are 95 new codes, 5 deleted and 15 revised codes. Most of the new codes and revisions involve molecular pathology, which is a growing field. Since many of these codes are inputting in the pathology or laboratory departments via chargemaster, the hospital will want to be sure the chargemaster is up to date and personnel in these departments are aware of the updates.
Evaluation and Management
For E&M there are 6 new codes, and 5 revised codes. The subsection for “Interprofessional Telephone/Internet/Electronic Health Record Consultations” updated with “Electronic Health Record” along with the notes.
“Electronic Health Record” was added to codes 99446-99449 for interprofessional telephone/internet/electronic health record assessment and management service.
The below two new codes were created to reflect the growing use of the online electronic health record to interact with patients.
- 99451 Interprofessional telephone/internet/electronic health record assessment and management service provided by a consultative physician, including a written report to the patient’s treating /requesting physician or other qualified healthcare professional, 5 minutes or more of medical consultative time
- 99452 Interprofessional telephone/internet/electronic health record referral services provided by a treating /requesting physician or other qualified healthcare professional, 30 minutes
Report 16-30 min of a service day for time spent preparing for the referral and/or communicating with
the patient using code 99452. If over 30 minutes, use prolonged services codes.
There is a new subsection for “Digitally Stored Data Services/Remote Physiologic Monitoring.” Report remote monitoring services such as weight, blood pressure, pulse oximetry during a 30 day period. The device must be a medical device as defined by the FDA.
- 99453 Remote monitoring of physiologic parameter(s) (eg, weight, blood pressure, pulse oximetry, respiratory flow rate), initial, set-up and patient education on use of equipment
(Do not report more than once per episode of care or for monitoring under 16 days
- 99454 Device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days.
(Do not report for monitoring under 16 days or if monitoring covered under another code)
▲ 99091 Collection and interpretation of physiologic data code was updated with adding “each 30 days” so this code can only be reported once per 30 days
There is another new subsection “Remote Physiologic Monitoring Treatment Management Services” with notes.
- 99457 Remote physiological monitoring treatment management services, 20 minutes or more of clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communications with the patient/caregiver during the month
This code is used when QHCP use the results of remote physiological monitoring to manage a patient under a specific treatment plan. It is also used when it does not meet requirements to report a more specific service. (Report once per 30 days regardless of the number of parameters monitored.
(Do not report 99457 with 99091)
One new code was created under the Chronic Care Management Services.
99491 Chronic care management services, provided personally by a physician or other QHCP at least 30 minutes of physician/QHCP time, per calendar month, with the following required elements:
- Multiple (2 or more) chronic conditions expected to last at least 12 months or death
- Chronic conditions place patient at risk of death, acute exacerbation or decline
- Comprehensive care plan established, implemented, revised or monitored
More E&M information in general:
Good news is CMS is delaying implementation of E/M payment changes. CMS will collapse payment rates for E/M office visits levels 2 through 4 rather than levels 2 through 5 beginning in 2021. CMS will keep a separate payment rate for level 5 visits to account for time and care associated with complex patients.
CMS has also eliminated the requirement to document the medical necessity of a home visit in lieu of an office visit.
For established patients history and exam, when relevant information is already contained in the medical record, practitioners may choose to focus their documentation on what has changed since the last visit, or on pertinent items that have not changed, and need not re-record the defined list of required elements if there is evidence that the practitioner reviewed the previous information and updated it as needed.
Additionally, CMS is clarifying that for new and established patients chief complaint and history, practitioners need not re-enter in the medical record information that has already been entered by ancillary staff or the beneficiary. The practitioner may simply indicate in the medical record that he or she reviewed and verified this information.
Beginning in CY 2021, CMS will implement payment, coding, and additional documentation changes for E/M office/outpatient visits, specifically:
- Single rates for levels 2 through 4 for established and new patients, maintaining the payment rates for E/M office/outpatient visit level 5 in order to better account for the care and needs of complex patients;
- Add-on codes for level 2-4 visits that describe the additional resources inherent in visits for primary care and particular kinds of non-procedural specialized medical care;
- A new “extended visit” add-on code for level 2 through 4 visits to account for the additional resources required when practitioners need to spend additional time with patients.
- For level 2 through 5 visits, choice to document using the current framework, MDM or time;
- When time is used to document, practitioners will document the medical necessity of the visit and that the billing practitioner personally spent the required amount of time face-to-face with the beneficiary (typical CPT time for code reported, plus any extended/prolonged time).
This concludes our five part series on new CPT codes for FY 2019! Happy Coding!
The information contained in this post is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.
In Part 5, we focused on identifying the approach being used for the spinal fusion. In Part 6, we are going to focus on identifying the type of bone graft used for the spinal fusion.
In Part 4, we focused on determining the spinal column being fused. In Part 5, we are going to focus on identifying what approach is being used to complete the spinal fusion (anterior, posterior or both).
This past year, HIA implemented “Buddy Up,” a program designed to help the new hire have a smooth transition into their new HIA roles with the assistance of a “buddy.” What is a Buddy? The Buddy is simply a peer who can guide the new hire in order to make them feel more comfortable. We are very proud of this program and have many success stories that we would like to share. Take a look at the wonderful feedback we have received below.
In Part 3, we focused on determining the level of the fusion(s) and how to determine the number of vertebrae fused. In Part 4, we are going to focus on identifying which column is being fused (anterior, posterior or both).
Part 3: Spinal Fusion Coding — Determine the Level(s) or Region of Fusion and Number of Vertebrae Fused
In Part 1, we learned the diagnoses associated with the need for spinal fusions, and in Part 2 the need to identify if the fusion is an initial or refusion of the vertebrae. In Part 3, we are going to focus on determining the level(s) of fusion, as well as the number of vertebrae fused.
In Part 2, we are going to look at the differences between initial fusion and a refusion. In ICD-9, there were specific codes to show if the fusion was an initial fusion, or if it was a refusion. In ICD-10-PCS, initial fusions and refusion procedures are coded to the same root operation “fusion.”
This is Part 1 of a 14 part series focusing on education for spinal fusions. Spinal fusion coding is a tough job for coders. There are so many diseases/disorders that result in the need for spinal fusion, and even more choices in reporting the ICD-10-PCS codes.
The official definition from the Centers for Medicare & Medicaid Services (CMS) states that a Medicare overpayment is a payment that exceeds amounts properly payable under Medicare statutes and regulations. When Medicare identifies an overpayment, the amount becomes a debt you owe the Federal government.
The question asked in a physician query may be the most important element of the document. Query questions need to be as simple and concise as possible. The physician should have no doubt what the coder is asking.
Coding complications of transplanted organs has always been a coding dilemma. With the implementation of ICD-10-CM that didn’t change. However, coders have multiple directives to help in determining what a complication of the transplant is vs. non-transplant conditions and diseases.
We interviewed our most productive coders, reviewers and members of our education team, asking them what steps they take to find a rhythm that works for them. This week, we talked with Beth Martilik, MA, RHIA, CDIP, CCS, Assistant Director of Education, about the steps she takes to find her routine.
With the implementation of ICD-10-CM came more codes for reporting many different conditions and diseases, and atrial fibrillation is one of those. For many years there was only one code available for reporting this condition, even when the physician further specified the type of atrial fibrillation that the patient had. In ICD-10-CM, there are four codes to report atrial fibrillation.
We have a case where the physician removes mucoid casts found during bronchoscopy. We have also seen mucus plugs removed during bronchoscopy. The MD performs bronchial washings then removes a large amount of tenacious and thick mucoid casts via bronchoscopy. Is this coded drainage, extirpation or excision? What body part is used?
The key to making the query process more efficient is to look for words or documentation while reviewing the record that may signal a potential query opportunity and to note the finding at that time. By the time a coder reaches the end of a record, documentation may have been found to eliminate the need for the query.
Question: This patient is noted to have “Lymphangitic carcinomatosis of lungs with mediastinal lymph nodes.” How would I code the diagnosis? Would I code metastatic cancer to the lung (C78.01) or metastatic cancer to the lymph nodes (C77.1)?
Coding these can be challenging for coders when trying to decipher the operative notes and terms that are used. The physicians are still using the terms excision and resection interchangeably and review of the entire operative note is required to select the appropriate root operation. Remember, it is the coder’s responsibility to determine the root operation based on the details from the physician in the operative report.
This would be considered a “mechanical” complication of the stent graft since the MD states it is a fracture of the endograft and it is folded over on itself. I would change T82.898A TO T82.598A for Other mechanical complication of other cardiac and vascular devices and implants, initial encounter. I did not use “displacement” because the surgeon did not state that the graft was displaced, only that it collapsed upon itself causing obstruction.
We interviewed our most productive coders and reviewers, asking them what steps they take to find a rhythm that works for them. This week, we talked with Valerie Abney, CDIP, RHIT, CCS, about the steps she takes to find her routine.
Osteoporosis alone is responsible for over a million fractures every year. Stress fractures are not as common but they do occur. There are more than 1 million total joint replacements in the U.S. each year, so there was a need to create codes for injuries that occur around or near the prosthesis. These are called “periprosthetic” fractures.
Back in April, the Office of the Inspector General (OIG) published a report detailing its findings from a review of two groups of high-risk diagnosis codes, acute stroke and major depressive disorder. The objective was to determine whether selected diagnosis codes submitted to the Centers for Medicare and Medicaid Services for use in CMS’s risk adjustment program complied with Federal requirements.
There seems to be differences of opinions on the issue of a 40w0day gestation Can you clarify if P08.21 should be assigned for 40w0day infant or if it would not be assigned unless the infant’s gestation age was 40w1day or greater?
Coders may find situations where a patient is documented as meeting SIRS or sepsis criteria, or has some clinical indicators reflective of possible sepsis, but the physician never documents sepsis as a diagnosis. Should the coder always query for sepsis in these instances?
In this example, would it be appropriate to code the complication code T82.03XA, Leakage of heart valve prosthesis, initial encounter as the principal diagnosis over the HFpEF (heart failure exacerbation) code?
A higher CMI corresponds to increased consumption of resources and increased cost of patient care, resulting in increased reimbursement to the facility from government and private payers, like CMS. We know that documentation directly impacts coding.
With the implementation of ICD-10-PCS more codes were developed in order to accurately report procedures. Spinal fusion coding is still a problematic coding issue and at times, even a coder’s nightmare. Coders often report only the code for the fusion thinking that one code would include all of the other procedures that are performed.
Answer: I would code 0HPT0NZ for removal of tissue expander from right breast, open and change 0HPT0JZ, removal of synthetic substitute from right breast, open, for removal of the acellular dermal matrix to 0HPT0KZ, Removal of nonautologous tissue substitute from right breast, open approach.
There are certain conditions that have instructional notes in the ICD-10-CM tabular/coding conventions that guide the coder in sequencing. This is especially true when the condition has a common manifestation or underlying conditions of a chronic disease. If there is a “code first” note in the tabular, the coder should follow this instruction and sequence the underlying etiology or chronic condition first followed by the manifestation as an additional diagnosis.
When it comes to coding and documentation, finding your own rhythm can lead to positive results. For our series, Find Your Routine, we interviewed our most productive coders and reviewers and asked them what steps they take to find a rhythm that works for them. This week, we talked with Meghan Schumacher, CPC, CPMA, Provider Coding Consultant at Health Information Associates, Inc., about the steps she takes to find her routine.
Last year, the Office of Inspector General (OIG) performed an investigation that found, “between 2014 and 2016, Medicare Advantage organizations overturned 75% of their preauthorization and payment denials upon appeal,” which is why, at HIA, we always advise our clients to engage in the appeals process.