2018 Coding Changes For Myocardial Infarction
There are important 2018 Coding Changes For Myocardial Infarction. The 2018 Guidelines for Acute Myocardial Infarction (AMI) are revised, specifying “type 1” AMI where required and guidelines are added for other types of MI:
1) Type 1 ST elevation myocardial infarction (STEMI) and non-ST elevation myocardial infarction (NSTEMI)
- The ICD-10-CM codes for Type 1acute myocardial infarction (AMI) identify the site, such as anterolateral wall or true posterior wall.
- Subcategories I21.0-I21.2 and code I21.3 are used for type 1ST elevation myocardial infarction (STEMI). Code I21.4, Non-ST elevation (NSTEMI) myocardial infarction, is used for type 1 non ST elevation myocardial infarction (NSTEMI) and nontransmural MIs.
- If a type 1NSTEMI evolves to STEMI, the STEMI code should be assigned. If a type 1 STEMI converts to NSTEMI due to thrombolytic therapy, it is still coded as STEMI.
2) Acute myocardial infarction, unspecified
- Code 9, Acute myocardial infarction, unspecified, is the default for unspecified acute myocardial infarction or unspecified type.
If only type 1STEMI or Transmural MI without the site is documented, assign code I21.3, ST elevation (STEMI) Myocardial Infarction of unspecified site.
3) AMI documented as nontransmural or subendocardial but site provided:
If an AMI is documented as nontransmural or subendocardial, but the site is provided, it is still coded as a subendocardial AMI.
4) Subsequent acute myocardial infarction
- A code from category I22, Subsequent ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction, is to be used when a patient who has suffered a type 1 or unspecifiedAMI has a new AMI within the 4-week time frame of the initial AMI.
- A code from category I22 must be used in conjunction with a code from category I21. The sequencing of the I22 and I21 codes depends on the circumstances of the encounter.
Note: Do not assign code I22 for subsequent myocardial infarctions other than type 1 or unspecified. For subsequent type 2 AMI assign only code I21.A1. For subsequent type 4 or type 5 AMI, assign only code I21.A9.
5) Other Types of Myocardial Infarction
The ICD-10-CM provides codes for different types of myocardial infarction.
- Type 1 myocardial infarctions are assigned to codes I21.0-I21.4.
- Type 2 myocardial infarction and myocardial infarction due to demand ischemia or secondary to ischemic balance, is assigned to code I21.A1, Myocardial infarction type 2 with a code for the underlying cause. I24.8, Other forms of acute ischemic heart disease for the demand ischemia should not be assigned. Sequencing of type 2 AMI or the underlying cause is dependent on the circumstances of admission. When a type 2 AMI code is described as NSTEMI or STEMI, code I21.A1 should be assigned. Codes I21.01-I21.4 should only be assigned for type 1 AMIs.
Acute myocardial infarctions type 3, 4a, 4b, 4c and 5 are assigned to code I21.A9, Other myocardial infarction type.
The “Code also” and “Code first” notes should be followed related to complications, and for coding of postprocedural myocardial infarctions during or following cardiac surgery.
Coding Carpal Tunnel Syndrome.
Carpal tunnel syndrome is diagnosed when there is pressure on the median nerve in the wrist. Some symptoms include pain, numbness, tingling, and weakness in the hand. The physician may order physical therapy, or prescribe a wrist brace or Non-steroidal anti-inflammatory drugs (NSAID). To achieve coverage and payment, the provider should document the conservative treatment provided, along with the patient’s response to these methods.
Following more conservative treatments, an injection performed in the wrist with corticosteroids and/or anesthetics can provide temporary relief of the symptoms. The injection is reported with 20526 Injection, therapeutic (eg, local anesthetic corticosteroid), carpal tunnel. If you perform this service in an office setting and purchase the medication, don’t forget to code for the corticosteroid using the appropriate HCPCS Level II code (In a hospital or outpatient setting, the facility codes for the drug).
CPT® 20526 is a unilateral code. To bill bilateral injections, either append modifier 50 Bilateral procedure or report the code on two lines and append modifiers RT Right side and LT Left side. Know the insurance carrier’s preference to determine if you should append modifier 50 or anatomical modifiers RT/LT.
A more productive intervention is for the physician to perform a release of the ligament, through either an endoscopic or open approach.
The endoscope is placed into the wrist through a small incision in the wrist joint. The scope is used to identify the carpal ligament, which is divided to relieve pressure on the median nerve and tendons. An endoscopic carpal tunnel release is reported with CPT® code 29848 Endoscopy, wrist, surgical, with release of transverse carpal ligament.
In an open approach, an incision is made over the carpal tunnel. The ligament is divided to release pressure on the median nerve, or the nerve may be relocated to relieve the pressure. An endoscope is not used in this procedure. The CPT® code to report this procedure is 64721 Neuroplasty and/or transposition; median nerve at carpal tunnel.
Both endoscopic and open carpal tunnel release surgeries are unilateral codes. To report bilateral injections, either append modifier 50 to the single code or bill the code on two lines and append modifiers RT and LT, depending on the insurance carrier’s preference.
The National Correct Coding Initiative Policy Manual for Medicare Services, updated Jan. 1, states:
CPT code 29848 describes endoscopic release of the transverse carpal ligament of the wrist. CPT code 64721 describes a neuroplasty and/or transposition of the median nerve at the carpal tunnel and includes open release of the transverse carpal ligament. The procedure coded as CPT code 64721 includes the procedure coded as CPT code 29848 when performed on the same wrist at the same patient encounter. If an endoscopic procedure is converted to an open procedure, only the open procedure may be reported.
Whether the patient is having an injection or surgery, consent is needed. Consent may be verbal for an injection given in a physician office, but must be in writing for surgery in a hospital or other outpatient setting. Most hospitals require consent forms to be filled out by the provider and signed by both the provider and the patient. For verbal consent, the provider must document that consent was obtained by the patient or the patient’s guardian.
Additionally, the physician should document the prep, the location, the needle, aspiration (if performed), drug, dosage, and how the patient tolerated the procedure.
ICD-10-CM breaks down carpal tunnel syndrome based on laterality. The codes are in Chapter 6, Diseases of the Nervous System:
G56.00 Carpal tunnel syndrome, unspecified upper limb
G56.01 Carpal tunnel syndrome, right upper limb
G56.02 Carpal tunnel syndrome, left upper limb
G56.03 Carpal tunnel syndrome, bilateral upper limb
Carpal tunnel surgery has a 90-day global period. Global periods can be found in the Physician Fee Schedule. Any evaluation and management (E/M) visits to the surgeon or the surgeon’s associates related to the carpal tunnel surgery are inclusive in the reimbursement for the surgery and cannot be separately reported.
If the physician performs internal neurolysis (such as a pain block) using an operating microscope during a carpal tunnel release using an open approach, report add-on code 64727 Internal neurolysis, requiring use of operating microscope (List separately in addition to for neuroplasty) (Neuroplasty includes external neurolysis) in addition to 64721. A parenthetical note states, “Do not report code 69990 in addition to code 64727.”
Check with the insurance carrier to verify if they require modifier 51 Multiple procedures when billing bilateral procedures on two lines using the anatomic modifiers RT/LT.
CMS considers coverage for Supervised Exercise Therapy.
Peripheral Artery Disease.
PAD is a vascular disease that stems from atherosclerosis (plaque buildup) which narrows the arteries affecting the lower extremities. The number of people diagnosed with PAD is estimated at more than 200 million worldwide, with approximately 12% of Americans having PAD. The presence of PAD becomes more prevalent with age, with PAD affecting more than 10% of patients in their 60s and 70s.
The diagnosis of PAD can be confirmed through the ankle-brachial index (ABI), which is the ratio of systolic pressure at the ankle to that in the arm, or the toe-brachial index for patients where ABI is not reliable due to noncompressible vessels, common for patients of advanced age or chronic diabetes. ABI results of 0.91 to 0.99 are considered borderline, with an ABI of 0.90 or less considered abnormal.
The most common symptom experienced by people with PAD is Intermittant Claudication, which affects about two million Americans, and eight million people globally. IC is pain/discomfort experienced in the legs that occurs while walking or exercising and resolves itself with rest. The pain from IC often limits PAD patients to very light activity since they are only capable of walking short distances. This often results in the elimination of many hobbies and work activities, which could have a dramatic impact on patients’ functional independence and quality of life (QoL). Exercise capacity which may be measured by several methods including 6 minute walk test, maximum walking distance, long distance corridor walking and others has been associated with all-cause mortality. While improvement in walking distance and time to claudication is important as a treatment goal, it is also believed that the impact of IC on overall function and general QoL could be minimized.
PAD is an underdiagnosed disease with debilitating consequences that disproportionately affects minority populations. Research has shown SET to be an effective, minimally invasive method to alleviate the most common symptom associated with PAD. This could also prevent the progression of PAD and lower the risk of cardiovascular events that are prevalent in these patients.
Practice guidelines from the American College of Cardiology Foundation/American Heart Association (ACCF/AHA) recommend SET as the initial treatment for patients suffering from IC (Gerhard-Hermanet al., 2016). While experts seem to agree that exercise therapy should be the initial treatment for PAD/IC, the number of endovascular revascularization (ER) procedures has been increasing (Spronk et al., 2008). The preference of physicians and patients for the more invasive ER treatment can be partly attributed to the limited access to SET programs, and the immediate result that is observed with ER (Spronk et al., 2008; van den Houten et al., 2016). ER has remained a more popular treatment option for claudication than SET, despite the ACCF/AHA recommendation that ER be reserved for cases where the patient is too functionally impaired for SET (Anderson et al., 2013).
- The Centers for Medicare & Medicaid Services (CMS) has determined that the evidence is sufficient to cover supervised exercise therapy (SET) for beneficiaries with intermittent claudication (IC) for the treatment of symptomatic peripheral artery disease (PAD). Up to 36 sessions over a 12 week period are covered if all of the following components of a SET program are met:
The SET program must:
- consist of sessions lasting 30-60 minutes comprising a therapeutic exercise-training program for PAD in patients with claudication;
- be conducted in a hospital outpatient setting, or a physician’s office;
- be delivered by qualified auxiliary personnel necessary to ensure benefits exceed harms, and who are trained in exercise therapy for PAD; and
- be under the direct supervision of a physician (as defined in 1861(r)(1)), physician assistant, or nurse practitioner/clinical nurse specialist (as identified in 1861(aa)(5)) who must be trained in both basic and advanced life support techniques.
Beneficiaries must have a face-to-face visit with the physician responsible for PAD treatment to obtain the referral for SET. At this visit, the beneficiary must receive information regarding cardiovascular disease and PAD risk factor reduction, which could include education, counseling, behavioral interventions, and outcome assessments.
- Medicare Administrative Contractors (MACs) have the discretion to cover SET beyond 36 sessions over 12 weeks and may cover an additional 36 sessions over an extended period of time. A second referral is required for these additional sessions.
SET is non-covered for beneficiaries with absolute contraindications to exercise as determined by their primary physician.
May is Melanoma Awareness Month.
Although melanoma accounts for less than 1 percent of skin cancers, The American Cancer Society warns that it causes most skin cancer deaths. More than 87,000 melanoma cases will be diagnosed this year, more commonly in women, 25-29 years old and an estimated 9,730 people will die of melanoma, the society claims. The five-year life expectancy is 98 percent for patients whose melanoma is detected early, but that number plummets when melanoma becomes invasive, spreading to vital organs or lymph nodes.
Normally identified as a black or irregularly colored asymmetric mole, the lesions can be light-colored, as well. Check yourself regularly, such as the bottom of your feet. If you have a suspicious spot, have your physician or a specialist inspect it.
Possible anywhere, but most frequently found on men’s trunks and women’s legs, a lesion springs from a damaged melanocyte, which are present in skin and hair follicles. Melanocytes also are found in the
cochlea, iris, and brain. Exposure to ultraviolet radiation prompts the melanocyte to produce more color to help protect the skin. This is determined by three distinct elements: enzymes in melanin synthesis, proteins for melanosome structure, and proteins for trafficking and distribution. It’s a complicated process that can produce several disorders, with melanoma being the most terrifying.
Melanoma has its own entry in the ICD-10-CM Index of Diseases and Injuries. Category C43 Malignant melanoma of the skin in Chapter 2: Neoplasms includes codes by the site. Codes for melanoma of the skin of genital organs are in categories C51-C52 and C60-C63. The Table of Neoplasms refers you to the Index, and the codes start on page 516. Be sure to read the Includes and Excludes notes carefully. And take care to report the required fourth and fifth characters.
Report Z12 Encounter for screening for malignant neoplasms during the visit, but never report a malignancy if it isn’t diagnosed by the physician.
Main types of skin biopsies are:
- Shave biopsy
- Punch biopsy
- Incisional biopsy
- Excisional biopsy
The physician may choose to do a fine needle aspiration of lymph nodes if there is fear the lesion has spread.
Staging is based on the T, N, and M categories:
- The T category addresses the tumor itself: How big is it and how fast are its cells splitting?
- The N category surveys if and how many lymph nodes reveal melanoma cells.
- The M category identifies how the tumor has metastasized.
According to the American Medical Association’s (AMA) CPT® Professional, during certain surgical procedures in the integumentary system, such as excision, destruction, or shave removals, the removed tissue is often submitted for pathologic examination. Obtaining tissue for pathology is a routine component of such procedures; it isn’t considered a separate biopsy procedure so it cannot be separately reported. Use CPT® code range 11100-11101 when the procedure to obtain tissue for pathologic examination is performed independently, or is unrelated or distinct from procedures performed at the same time.
Mohs surgery (17311-17315) is ideal for basal and squamous cell cancers, but cell damage during the procedure may mask melanoma from a distinct diagnosis. Normally, melanomas are sent to an outside lab for special stains that can’t be done in the office during a Mohs. Some physicians have adapted their techniques to effectively use Mohs on thin melanomas. (See the article “Don’t Marginalize Mohs” on pages 26-27 for detailed information on Mohs.)
Standard excision (11600-11646) is coded by the margin taken around the lesion. Report the whole excised wound, which includes both the width of the lesion and the margin. The margin of skin is removed until there’s confidence the whole tumor has been removed. The closure is separate: Report 12031-12057 for intermediate and 13100-13153 for complex work. Destruction is performed by electrosurgery, cryosurgery, laser, or chemicals (17260-17286).
If melanoma spreads, the physician and patient can choose surgery, adjuvant radiation, or chemotherapy as treatment. Advances in immunotherapy and targeted therapy, including new drugs to help promote the success of these new approaches, are exciting. Immunotherapy uses the patient’s own genes and white cells to target and kill the cancer cells. Targeted therapy dips into the molecular level of the disease and offers great promise.
Latest changes in ICD-10-PCS.
ICD-10-PCS changes for 2018:
The U.S. Department of Health & Human Services (HHS) has released the code changes for ICD-10-PCS coding system. ICD-10-PCS codes were adopted under HIPAA for hospital inpatient healthcare settings to use for reporting procedures. Their guidelines help healthcare providers and coders accurately identify procedures to be reported on healthcare claims.
The 2018 updates will reflect services from Oct. 1, 2017 through Sept. 30, 2018, so be sure to update your medical records to account for the changes.
There were 75,789 codes in 2017 and in 2018 the number jumps to 78,705 with:
- 3562 new codes;
- 1,821 revised codes; and
- 646 deleted codes.
The changes, which include:
- In the Medical and Surgical section, body part values are revised or streamlined for clarity and usefulness as coded data.
- Endoscopic approaches are added to various tables throughout the system for completeness.
- ICD-10-PCS guidelines are updated with new and revised guidelines.
The 2018 General Equivalence Mappings (GEMs) will be posted in August 2017.
ICD 10 Coding for Keratosis.
Actinic keratosis (AK) is a small, rough spot on the skin. It usually occurs in middle-aged and older individuals, and may also be called senile keratosis or solar keratosis. AK is a premalignant lesion, which may develop into skin cancer. Although clinicians generally can diagnose AK by examining the area, biopsy may be necessary.
AK typically develops in fair-skinned individuals, those with excessive sun exposure, or individuals with indoor tanning radiation. Treatment for AK is generally straightforward, and may include cryosurgery (freezing), scraping, and photodynamic therapy.
Seborrheic keratosis (SK) may present as single or multiple elevated plaques and nodules that are often hyperpigmented (darkened) with an overgrown, greasy surface. This type of SK is benign, of unknown cause, and involves only the top layers of the epidermis. No treatment is necessary, although there is a risk of irritation or infection caused by friction (such as when clothing rubs the area) or “picking,” which may warrant removal by electrocautery or shave excision.
Clinical documentation of keratosis should include the type of keratosis—actinic or seborrheic—and whether the keratosis is inflamed (or not otherwise specified). The location of the growths must be noted, as should contributing factors, such as tanning bed exposure.
CD-10-CM codes for actinic keratosis and seborrheic keratosis are in different subcategories.
Category L57.0 describes AK, including keratosis not otherwise specified, solar keratosis, and senile keratosis. Subcategory L57.0 requires that you use an additional code to identify the source of the ultraviolet radiation.
Subcategory L82 contains codes for SK, and includes dermatosis papulosa nigra and Leser-Trelat disease.
- L82.0 Inflamed seborrheic keratosis
- L82.1 Other seborrheic keratosis
L82 also contains an Excludes II note telling the user that codes for seborrheic dermatitis (L21-) may be cited, in addition to the L82 code, if both are supported by documentation.
New modifier for Hemodialysis.
Hemodialysis is typically furnished three times per week in sessions of three to five hours duration, according to Medicare policy. For a 30-day month, payment is limited to 13 treatments and for a 31-day month, payment is limited to 14 treatments.
Append Modifier CG, policy criteria apply to the claim line for the date of service associated with the excess treatment that does not meet medical justification requirements, as defined by the Medicare administrative contractor (MAC), effective Oct. 1, 2017.
Newly issued modifier CG indicates that the facility attests the additional treatment does not meet justification requirements and should not be paid separately under the End Stage Renal Disease Prospective Payment System (ESRD PPS).
This modifier applies to the 72x type of bill with revenue code 0821 or 0881 and CPT code 90999 Unlisted dialysis procedure, inpatient or outpatient.
Extra hemodialysis sessions may be covered in a month if the service is ascertained by a licensed healthcare professional acting within his or her scope of practice. In addition, there must be a physician’s order for these medically necessary additional sessions. This must be documented in the medical record and made available to Medicare upon request.
The medically necessary extra HD sessions must be indicated on the claim form with the use of the CPT code 90999 and modifier KX Specific required documentation on file; and documentation related to these additional sessions must show appropriate medical justification as outlined in the MAC’s policy.
Mohs surgery for Skin Cancer.
When reporting Mohs surgery for treatment of skin cancer, documentation must confirm that a single provider acted as both the surgeon (excising tissue) and pathologist (immediately examining excised tissue to determine clear margins). “If either of these responsibilities is delegated to another physician or qualified healthcare professional who reports the services separately the … [Mohs] codes should not be reported,” according to CPT® requirements.
The physician removes tissue in stages and begins by excising the lesion. This is the first stage. The specimen is divided into smaller portions, called blocks. The locations of each block within this stage are carefully mapped, and each block is examined for cancer cells.
17311 Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (eg, hematoxylin and eosin, toluidine blue), head neck, hands, feet, genitalia or any location with surgery directly involving muscle, cartilage, bone, tendon, major nerves or vessels; first stage, up to 5 tissue blocks
+17312 Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (eg, hematoxylin and eosin, toluidine blue), head neck, hands, feet, genitalia or any location with surgery directly involving muscle, cartilage, bone, tendon, major nerves or vessels; each additional stage after the first stage, up to 5 tissue blocks (List separately in addition to code for primary procedure)
17313 Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (eg, hematoxylin and eosin, toluidine blue), of the trunk, arms or legs; first stage, up to 5 tissue blocks
+17314 Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (eg, hematoxylin and eosin, toluidine blue), of the trunk, arms or legs; each additional stage after the first stage, up to 5 tissue blocks (List separately in addition to code for primary procedure)
+17315 Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (eg, hematoxylin and eosin, toluidine blue), each additional block after the first 5 tissue blocks, any stage (List separately in addition to code for primary procedure)
When billing for Mohs, many common services are included, but there are exceptions.
Mohs surgery includes “routine stains,” such as hematoxylin and eosin (H&E) or toluidine blue. If the physician performs an additional, atypical stain, report the appropriate special stain code. CPT® instructs, “When a non-routine histochemical stain on frozen tissue is utilized, report 88314 [Special stain including interpretation and report; histochemical stain on frozen tissue block (List separately in addition to code for primary procedure)] with modifier 59.”
Finally, CPT® tells us that if a repair is performed following Mohs, “use separate repair, flap, or graft codes.”
Histopathologic examination is included in the Mohs procedure. Do not separately report 88302-88309.
Spine Procedural Coding.
There are many 2017 CPT® code changes to spine procedures for 2017.
Coders should note that the moderate sedation symbol (¤) was removed from the vertebroplasty (22510-22512) and vertebral augmentation (22513-22515) codes. These codes no longer include moderate sedation, which can now be reported separately, as appropriate, using 99151-99157.
Two injection codes are deleted and replaced with four new codes to describe interlaminar epidural or subarachnoid injections. The differentiating factors between the four codes are two-fold:
- The spinal region where the injection is performed; and
- Whether the injection is performed with or without imaging guidance.
The new codes are as follows:
CPT® guidelines state not to report 62320-62323 with +77003 Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid) (List separately in addition to code for primary procedure), 77012 Computed tomography guidance for needle placement (eg, biopsy, aspiration, injection, localization device), radiological supervision and interpretation, or 76942 Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation.
CPT® codes 62318 and 62319 are deleted.
Again, CPT® guidelines state not to report 62320-62323 with imaging codes +77003, 77012, or 76942.
CPT® 22305 is deleted because current clinical practice reflects a low utilization of this code. CPT® guidelines now instruct providers to use an evaluation and management (E/M) code for this service.
Category II codes 0171T and +0172T are deleted. Replacement codes are differentiated by whether decompression was also performed for codes 22867,+22868,22869,+22870.
These codes do not describe procedures for arthrodesis or fusion devices; the devices are used for only spinal stabilization and/or distraction.
Like all open spine procedure codes, these codes include imaging guidance (e.g., fluoroscopy) as needed to perform the procedure. CPT® guidelines state that 22867-22870 may not be reported with other spine procedure codes including specific arthrodesis, instrumentation, and decompression codes. The CPT® codebook provides further guidance.
A major spine procedure code change was the deletion of +22851 and the creation of three new codes.
The most common code that spine surgeons will use is +22853 Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace (List separately in addition to code for primary procedure). This code may be used for anterior or posterior procedures; it is not limited to only anterior spine procedures.
CPT® clearly states that +22853 includes the placement of any anterior integral instrumentation (meaning the anterior plate is necessary to use with the device), when performed. This distinction was not clear with the old code (+22851). As a result, some incorrectly reported +22851 and +22845 Anterior instrumentation; 2 to 3 vertebral segments (List separately in addition to code for primary procedure), when only +22851 was appropriate.
The intervertebral device with an integrated anterior plate, also called a “low profile” or “stand-alone” device, is accurately reported using only +22853. It is incorrect to separately report +22845 if an integrated plate was used to secure the device into the interspace.
How will you know if the device should be reported using +22853 only, or using both +22853 and +22845? The spine surgeon should document in the operative report the specific trade name of the spinal implant so the correct code(s) are reported. You can also look up the device on the internet to see what it looks like and determine if it qualifies for one or two codes.
The remaining two intervertebral device codes are:
+22854 Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh, methylmethacrylate) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to vertebral corpectomy(ies) (vertebral body resection, partial or complete) defect, in conjunction with interbody arthrodesis, each contiguous defect (List separately in addition to code for primary procedure)
+22859 Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh, methylmethacrylate) to intervertebral disc space or vertebral body defect without interbody arthrodesis, each contiguous defect (List separately in addition to code for primary procedure)
CPT® +22854 is used when an intervertebral device is placed into a corpectomy (removal of the vertebral body) defect and arthrodesis is performed. For example, a C6 corpectomy is performed with discectomies at C5-C6 and C6-C7 with preparation of the C5 and C7 endplates. An expandable titanium cage packed with bone graft for arthrodesis is placed into the corpectomy defect, and a plate is secured to C5 and C7. The expandable titanium cage is reported using +22854 because it was placed in a corpectomy defect and arthrodesis was performed.
The typical example of +22859 is a methylmethacrylate spinal reconstruction of a resected vertebral body where there is no arthrodesis.
Several instructional and add-on code parenthetical notes are added throughout the CPT® codebook to clarify the deletion of +22851 and the addition of these three new codes.
CPT® 2017 adds new lumbar endoscopic decompression code 62380 Endoscopic decompression of spinal cord, nerve root(s), including laminotomy, partial facetectomy, foraminotomy, discectomy and/or excision of herniated intervertebral disc, 1 interspace, lumbar. This code may be reported with modifier 50 Bilateral procedure when performed bilaterally.
This procedure is performed endoscopically, which CPT® now defines as having “continuous direct visualization” of the spinal structures through an endoscope.
This new code resulted in revising code 62287 Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, any method utilizing needle based technique to remove disc material under fluoroscopic imaging or other form of indirect visualization, with discography and/or epidural injection(s) at the treated level(s), when performed, single or multiple levels, lumbar, also known as the percutaneous intervertebral disc decompression code, to remove the words “with the use of an endoscope.”
Two Category III codes were also revised to remove the words “with or without the use of an endoscope,” in accordance with the new definitions of operative approaches previously discussed:
0274T Percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy), any method, under indirect image guidance (eg, fluoroscopic, CT), single or multiple levels, unilateral or bilateral; cervical or thoracic
Percutaneous procedures are image-guided without direct visualization of the spinal structures.
New changes to E/M service may clear up the confusion.
Under the current 1995 Documentation Guidelines for Evaluation and Management (E/M) Services, 2-7 body parts and/or organ systems are examined for both the expanded problem-focused visit and detailed physical exam visit.
Effective for dates of service on or after July 1, 2017, (and applicable only to claims submitted to NGS) a detailed exam involves 6-7 body areas or organ systems, and an expanded problem-focused exam involves 2-5 body areas or organ systems.
Now maybe it is the perfect time to institute training and education to providers and coding staff regarding the new change to one of the key components of E/M services. Training may also include:
- A diligent approach toward quality examination documentation;
- Coding and documentation compliance issues for upcoding and downcoding;
- How the physical examination section should always align with the history of present illness section and care plan area of the note, with medical necessity clearly detailed.
This one small change makes educating providers on how to select a level of service a much more approachable learning opportunity.