Part 4: New 2020 CPT Codes | Digestive, Urinary, Nervous, Ocular and Auditory Systems
RHIA, CDIP, CCS, CCS‑P, CIRCC
Executive Director Of Education
AHIMA‑Approved ICD‑10‑CM/PCS Trainer and Ambassador
This is Part 4 of a five part series on the new 2020 CPT codes. In this series we will explore the CPT changes for FY 2020 and include examples to help the coder understand the new codes. There is 3 new digestive system codes with 1 deletion and 2 revised; 1 revised urinary system codes with new category III codes; 6 new with 20 deleted nervous system codes with 3 revisions; 2 new eye codes with 3 revisions; and finally a new category III auditory code.
Digestive System – Hemorrhoidectomy and Pelvic Exploration
There has been two revised codes for internal hemorrhoidectomy to denote without imaging guidance and one new code for internal hemorrhoidectomy via trans anal dearterialization:
▲46945 Hemorrhoidectomy, internal, by ligation other than rubber band; single hemorrhoid column/group, without imaging guidance
▲46946 Hemorrhoidectomy, internal, by ligation other than rubber band; 2 or more hemorrhoid columns/groups, without imaging guidance
- 46948 Hemorrhoidectomy, internal, by trans anal hemorrhoidal dearterialization, 2 or more hemorrhoid columns/groups, including ultrasound guidance, with mucopexy, when performed
Code 46948 had been category III code 0249T which has been deleted.
Dearterialization is ligating all arteries leading to the hemorrhoid column to decrease the blood flow to them. Mucopexy is a ring of sutures to pull-up a prolapse. If dearterialization is of a single hemorrhoid column/group only, assign 46999.
Two new codes were created for pelvic exploration for pelvic trauma:
- 49013 Preperitoneal pelvic packing for hemorrhage associated with pelvic trauma, including local exploration
- 49014 Re-exploration of pelvic wound with removal of preperitoneal pelvic packing, including repacking, when performed
Created for preperitoneal pelvic packing for hemorrhage associated with pelvic trauma.
These codes differ from other exploration procedures in that a laparotomy is not performed. Instead a low-horizontal Pfannenstiel incision is made just above the pubic rim, with dissection carried out until the urinary bladder is identified, without opening up the peritoneum. The re-exploration code is used if there is need for repacking or there is continued bleeding that needs repacking.
Urinary/Reproductive Systems – Orchiopexy Revision, Ablation of Prostate, Balloon Continence Device, Fallopian Tube Occlusion
Code 54640 was revised as below:
▲ 54640 Orchiopexy, inguinal or scrotal approach with or without hernia repair scrotal approach
This code was adjusted to remove the approach and the hernia repair reference. The “with or without hernia repair” conflicted with the intention to allow separate reporting of inguinal hernia repair when performed as instructed. Both inguinal and scrotal approaches are typical.
- 0582T Transurethral ablation of malignant prostate tissue by high-energy water vapor thermotherapy, including intraoperative imaging and needle guidance.
When the vapor needle location is confirmed, then periprostatic saline infusion is done followed by vapor delivery into the target at standard setting of 400 calories per vapor treatment is performed, ablating the malignant prostate tissue.
Four new codes were created for Transperineal balloon continence devices:
- 0548T Transperineal periurethral balloon continence device; bilateral placement, including cystoscopy and fluoroscopy
- 0549T … unilateral placement, including cystoscopy and fluoroscopy
- 0550T … removal, each balloon
- 0551T … adjustment of balloon(s) fluid volume
Current codes exist for insertion, removal, replace and repair of artificial urinary sphincter. More codes exist for placement removal and revision of male mesh sling.
The above procedure involves scout cystoscopy, filling of bladder with contrast and saline, prime adjustable continence device with isotonic solution, the two incisions on either side of midline of perineum, placing balloon in bladder neck, dilatation, and then slide U channel sheath device into bladder neck. And example is the ProACT device with information here: https://www.proact-for-men.com/for-physicians
Two new codes were created for permanent fallopian tube occlusion:
- 0567T Permanent fallopian tube occlusion with degradable biopolymer implant, transcervical approach, including transvaginal ultrasound
- 0568T Introduction of mixture of saline and air for sonosalpingography to confirm occlusion of fallopian tubes, transcervical approach, including transvaginal ultrasound and pelvic ultrasound.
The polymer is temporary and eventually degrades. Transcervical approach is accessing fallopian tubes through the cervix entrance.
Nervous System – Various New Codes and Updated Injection Codes
Spinal puncture codes were updated and added to denote diagnostic vs therapeutic spinal puncture and if with fluoro or CT guidance:
▲62270 Spinal puncture, lumbar, diagnostic;
- 62328 … with fluoroscopic or CT guidance
▲62272 Spinal puncture, therapeutic, for drainage of cerebrospinal fluid (by needle or catheter);
- 62329 … with fluoroscopic or CT guidance
Coders must not report 62328 and 62329 with 77003, 77012. If ultrasound or MRI guidance is performed see 76942, 77021 instead of using the “with fluoro/CT” codes.
Injection codes have been updated as follows:
▲64400 Injection(s), anesthetic agent(s) and/or steroid; trigeminal nerve, any division or branch each branch (ie, ophthalmic, maxillary, mandibular)
All codes in the family include the same editorial changes. The codes revised are 64405, 64408, 64416, 64417, 64418, 64425, 64430, 64435, 64446, 64448, 64449, and 64450
There are new introduction notes at the Somatic Nerves subsection to describe how and when these codes are reported. (i.e., how many injections, if imaging is included). Somatic nerves are is the part of the peripheral nervous system associated with the voluntary control of body movements via skeletal muscles. The somatic nervous system consists of afferent nerves or sensory nerves, and efferent nerves or motor nerves. Other updates include adding “level” to show more specificity in the codes:
▲64415 … brachial plexus, single
▲64420 … intercostal nerve, single level
+▲64421 … intercostal nerve, multiple, regional block, each additional level (List separately in addition to code for primary procedure)
▲64445 … sciatic nerve, single
▲64447… femoral nerve, single
64402 Injection, anesthetic agent; facial nerve
64410 Injection, anesthetic agent; phrenic nerve
64413 Injection, anesthetic agent; cervical plexus
Use 64999 for the facial, phrenic or cervical plexus
New codes were added for destruction, radiofrequency ablation and injection of agents into nerves of sacroiliac joint and genicular nerve:
- 64451 Injection(s), anesthetic agent(s) and/or steroid; nerves innervating the sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography) (For bilateral procedure, use -50)
- 64454 Injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, including imaging guidance, when performed
Code 64454 REQUIRES injection of ALL THREE of these branches: Superolateral, superomedial, inferomedial. If not three, use 64454-52.
There is a new chart on page 437 of the CPT Professional book that outlines the different injections and if they include imaging guidance or not.
- 64624 Destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed. This is done for pain from osteoarthritis of the knee.
Code 64624 REQUIRES destruction of each of the following genicular nerve branches: superolateral, superomedial, and inferomedial. If neurolytic agent is not applied to ALL THREE, use 64634-52.
- 64625 Radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography) For bilateral procedure use -50. If with ultrasound, use 76999. A photo here shows the three genicular nerves: https://bmjopen.bmj.com/content/7/11/e016377
Radiofrequency ablation (RFA) is a procedure used to reduce pain. An electrical current produced by a radio wave is used to heat up a small area of nerve tissue, thereby decreasing pain signals from that specific area.
Five new Category III codes were added for posterior tibial nerve neurostimulation, sometimes abbreviated as PTNS. PTNS is the least invasive form of neuromodulation used to treat overactive bladder and associated symptoms of urinary urgency, frequency, and incontinence. A fine needle electrode is inserted into the lower inner leg and the goal is to send stimulation through the tibial nerve. More information can be found here: https://simonfoundation.org/ptns/
- 0587T Percutaneous Implantation OR replacement of integrated single device neurostimulation system including electrode array and received or pulse generator, including analysis, programming, and imaging guidance when performed, posterior tibial nerve
- 0588T REVISION OR REMOVAL of integrated single device neurostimulation system including electrode array and received or pulse generator, including analysis, programming, and imaging guidance when performed, posterior tibial nerve
- 0589T Electronic analysis with simple programming of implanted integrated neurostimulation system…… 1-3 parameters
- 0590T Electronic analysis with simple programming of implanted integrated neurostimulation system…… 4 or more parameters
Ocular and Auditory Systems
New and revised codes were added as follows:
- 0563T Evacuation of Meibomian Glands using heat delivered through wearable open-eye eyelid treatment devices and manual gland expression, bilateral (for manual evacuation of meibomian glands use E&M code)
▲66711 Ciliary body destruction; cyclophotocoagulation, endoscopic, without concomitant removal of crystalline lens
▲66982 Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (eg, iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage; without endoscopic cyclophotocoagulation
- 66987 … with endoscopic cyclophotocoagulation (ECP)
▲66984 Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification); without endoscopic cyclophotocoagulation
- 66988 … with endoscopic cyclophotocoagulation (ECP)
ECP uses a laser endoscope containing three fiber groupings: an image guide, a light source, and the semiconductor diode laser. This technology allows direct visualization of the ciliary epithelium. This allows the laser energy to be precisely delivered to the ciliary processes, thus limiting damage to the underlying ciliary body and surrounding tissue.
- 0583T Tympanostomy (requiring insertion of ventilating tube) using an automated tube deliver system, iontophoresis local anesthesia.
The TULA System is a new technology for the placement of tympanostomy tubes in children with otitis media. The procedure is performed using local anesthesia in an outpatient setting. Traditional tympanostomy tube placement is performed by surgeons in an operating room under general anesthesia, resulting in the substantial use of health care resources, patient and caregiver anxiety, and caregiver absence from work. The TULA System (Acclarent, Inc., Menlo Park, California) is made up of two devices and coaching tools. The TULA IONTOPHORESIS SYSTEM is a headset equipped with single-use earplugs. Iontophoresis is a method to actively move charged drug molecules through the skin using low levels of electrical current. Ear electrodes within the earplugs connect to a control unit to deliver bilateral local anesthetic over ten minutes to the tympanic membrane. The TULA TubeDelivery System is used to make an incision in the tympanic membrane and insert a pre-loaded tympanostomy tube in a single automated motion. The entire procedure can be performed in an outpatient setting such as a clinic or doctor’s office.
Our final Part 5 of the series will cover miscellaneous CPT updates not covered thus far such as Evaluation and Management.
The information contained in this coding advice 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.
This is Part 1 of a 4 part series on the FY2021 changes to ICD-10 and the IPPS. In this part, we discuss some of the new ICD-10-CM diagnosis changes. Here is the breakdown: 72,616 total ICD-10-CM codes for FY2021; 490 new codes (2020 had 273 new codes); 58 deleted codes (2020 had 21 deleted codes); 47 revised codes (2020 had 30 revised codes)
Acute pulmonary edema is the rapid accumulation of fluid within the tissue and space around the air sacs of the lung (lung interstitium). When this fluid collects in the air sacs in the lungs it is difficult to breathe. Acute pulmonary edema occurs suddenly and is life threatening.
“Client S” is a small, not-for-profit, 40 bed micro-hospital in the Southeast. HIA performed a 65-record review this year for Client S and found an opportunity with 15 of them. 9 had an increased reimbursement with a total of $43,228 found.
The coma scale codes (R40.2-) can be used in conjunction with traumatic brain injury codes, acute cerebrovascular disease or sequelae of cerebrovascular disease codes. These codes are primarily for use by trauma registries, but they may be used in any setting where this information is collected. The coma scale may also be used to assess the status of the central nervous system for other non-trauma conditions, such as monitoring patients in the intensive care unit regardless of medical condition.
In the past, there had been an Excludes1 note at I46.- Cardiac arrest that excluded R57.0, Cardiac shock. HIA had also received a letter from AHA on a case in the past that had stated that only I46.- Cardiac arrest would be coded if both were documented. In addition, the Third Quarter Coding Clinic page 26 had a similar case that asked if both could be coded, and AHA had instructed that only I46.9, cardiac arrest, cause unspecified would be coded if both were documented and that the CDC would be looking at possible revision to the Excludes1 note.
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.
Lately we have seen several cases where the endarterectomy was assigned along with the coronary artery bypass (CABG) procedure when being performed on the same vessel to facilitate the CABG. A coronary artery endarterectomy is not always performed during a CABG procedure, so when it is performed it becomes confusing as to whether to code it separately or not.
Assign code Z20.828, “Contact with and (suspected) exposure to other viral communicable diseases” for all patients who are tested for COVID-19 and the results are negative, regardless of symptoms, no symptoms, exposure or not as we are in a pandemic.
The Centers for Medicare & Medicaid Services (CMS) announced new procedure codes for treatments of COVID-19 – effective as of August 1, 2020. Among the new codes are Section X New Technology codes for the introduction or infusion of therapeutics including Remdesivir, Sarilumab, Tocilizumab, transfusion of convalescent plasma, as well as introduction of any other or new therapeutic substances for the treatment of COVID-19.
One common element in many value-based programs is risk adjustment using Hierarchical Condition Categories (HCCs) to create a Risk Adjustment Factor (RAF) score. This method ranks diagnoses into categories that represent conditions with similar cost patterns.
Why are so many AKI records being denied? It’s hard to give one answer for why so many AKI records are being denied lately, but most appear to be due to the multiple sets of criteria available for use in determining if a patient has AKI, as well as physician documentation. As stated in Part 3 of this series, there are three main criteria/classifications used to diagnose AKI.
In previous parts of this series we looked at the definitions of AKI/ARF, causes, coding and sequencing, and the common clinical indicators that patients present with that are diagnosed with this condition. In Part 4, we will look at the documentation that should be present to report the diagnosis without fear of denial, as well as when a query is needed to clarify the diagnosis.
If the facility does a COVID-19 test, and test is negative, do I need a diagnosis code. The answer is yes, you will report a Z-code. The Z-code depends on the record documentation and circumstances of testing. For any patient receiving a COVID-19 test, if negative, there MUST e a Z-code to describe why the test was taken. (Test negative for COVID-19 and MD does not override negative results).
In the first parts of this series we looked at definitions of AKI/ARF, causes, coding and sequencing. In Part 3, we will look at what clinical indicators would possibly be present to support the diagnosis of AKI/ARF.
The FY2021 IPPS Proposed Rule is out and here are some highlights from it regarding ICD-10 Code proposals. We will know if these changes are permanent after the public comment period is over on July 10, 2020 and CMS prepares the Final Rule, usually out by August 1.
As discussed in Part 1 of this series, AKI/ARF is a common diagnosis that coders see daily. In Part 2, we are going to focus on the different types/specificity of AKI/ARF. We’ll learn what they mean, as well as how to code the diagnosis.
This is part 1 in a series focused on coding of acute kidney injury (AKI) and/or acute renal failure (ARF). AKI/ARF is reported often, but is also one of the most common diagnosis found in denials.
With the proliferation of COVID-19 cases, we thought we would put together a quick reference listing of some of the common scenarios that coders have asked about. As with all coding, coders should follow Official Guidelines for Coding and Reporting and the COVD-19 Frequently Asked Questions document by the AHA.
Effective March 1, Medicare will pay physicians for telehealth services at the same rate as in-person visits for all diagnoses, not just services related to COVID-19. This great for providers whose patients are reluctant to visit the office.
The biggest reasons why some hospital systems are moving to single path coding is to eliminate duplicative processes and to optimize productivity. In addition, costs are reduced when only one coder “touches” the record and completes both types of coding.
Effective with 4/1/2020 discharges, ICD-10-CM code U07.0 is used to report vaping -related disorders. ICD-10-CM code U07.0 (vaping related disorder) should be used when documentation supports that the patient has a lung-related disorder from vaping. This code is found in the new ICD-10-CM Chapter 22. U07.0 will be in listed in the ICD-10-CM manual under a new section: Provisional assignment of new disease of uncertain etiology or emergency use.
The US government and public-health officials are urging consumers to utilize telemedicine for remote treatment, fill prescriptions and get medical attention during the new coronavirus pandemic. The goal is to keep people with symptoms at home and to practice social distancing if their condition doesn’t warrant more intensive hospital care.
Coronavirus: Tips for working from home. Companies around the world have told their employees to stay home and work remotely. Whether you’re a new to this concept or a work from home veteran, here’s some tips to staying productive from our #HIAfamily.
This is part two of a three part series in which we address how coders can better interact with Clinical Documentation Improvement (CDI) professionals. In this part, we discuss mismatches and how to best go about resolving them. In part three we will provide a case example of best practice interaction.
This is part one of a three part series in which we address how coders can better interact with Clinical Documentation Integrity (CDI) professionals. Many times these departments are separate and the remote environment makes it difficult to interact efficiently between the two departments. In part one, we will discuss the history and objectives of CDI so the coder has a better understanding of CDI’s role.
One reason that coders should report chronic conditions (including history and status codes) on outpatient records is the HCC’s—Hierarchical Condition Categories. The quick and easy explanation of what HCC’s are is each HCC is mapped to certain ICD-10-CM codes or code ranges. HCC coding is designed to estimate future health care costs for patients.
For Part 5 of this 5-part series, we will look at Chapter 4 within ICD-10-CM—E00-E89—Endocrine, Nutritional, and Metabolic Diseases. There is no possible way to include every guideline or coding reference for this chapter, but here are some of the most common issues.
For Part 4 of this 5-part series, we will look at Chapter 10 within ICD-10-CM—J00-J99—Diseases of the Respiratory System. There is no possible way to include every guideline or coding reference for this chapter, but here are some of the most common issues.
For Part 3 of this 5 part series, we will look at Chapter 9 within ICD-10-CM—I00-I99—Diseases of the Circulatory System. This chapter contains so many of the everyday diagnoses that we code such as hypertension, heart disease and stroke.