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Prior to the end of the year, groups that work with medical coding should review the changes to determine which affect their organization.

Navigating health reform

2016 CPT® Coding Changes Include Revised Language and New Codes

  • 12/11/2015

Every November, the American Medical Association (AMA) hosts the Current Procedural Terminology (CPT®) and Resource-Based Relative Value Scale Annual Symposium to address upcoming CPT coding changes.

If there was one word to sum up the theme of this year’s symposium it would be ‘bundling,’ and procedures most affected are associated with interventional radiology. The AMA outlined initiatives that model codes after alternative payment models where one global fee is received for care provided to a defined population.

Relative Value Scale Update Committee

In addition to the detailed presentations on the CPT code changes, the AMA discussed its work within the Relative Value Scale Update Committee (RUC). This panel of physicians makes recommendations to the government on the resources required to provide the medical services described in the CPT code. The RUC highlighted some milestones, which included:

  • January 1, 2013 — Medicare began payments for CPT codes 99495 and 99496 for Transitional Care Management (TCM)
  • January 1, 2015 — Medicare implemented payment for code 99490, Chronic Care Management (CCM)

Starting January 1, 2016, Medicare will begin payment for Advanced Care Planning codes 99497 and 99498. These require a face-to-face service, and the update discussed counseling and advanced directives (the relative value unit (RVU) for 99497 = 1.50; the RVU for 99498 = 1.40).

Changes effective January 1, 2016

Prior to the end of the year, the revenue cycle/chargemaster team, physician practice managers and billers, and outpatient hospital coders should review each chapter to determine which changes affect their organization. In some cases, the use of the codes have been clarified or changed, and this information should be shared with all affected departments, as well as the coding staff. Clinicians in pathology and radiology should be aware of revised, added, or deleted codes.

Specific coding changes

The Evaluation and Management section has changes pertaining to codes for prolonged services and preventive care. Some codes have been revised, and the section provides additional guidance on the use of these codes.

The Advisory Committee on Immunization Practices (ACIP) vaccine recommendations are now included in CPT as well. The CPT vaccine code descriptions now explain the vaccine product to capture standardized vaccine abbreviations. This revision affects the descriptions of 45 CPT codes.

There is now a health care common procedure coding system (HCPCS) code to capture services provided to pre-diabetic patients. HCPCS 0403T describes this prevention program assigned for individuals with a high risk of developing Type II diabetes. Providers should check with local carriers on Medicare reimbursement for this code.

Providers should also pay close attention to the changes in the Interventional Radiology sections of the CPT manual. Some sections have revised codes, which now include the imaging guidance or the radiologic supervision and interpretation, but sections where there were no revisions have not bundled these services. The following sections were revised:

  • Intravascular Ultrasound Services (IVUS: 37252 and 37253)
  • Genitourinary Procedures (503XX – 507XX) — This section includes guidance on bundling of imaging and guidelines for these codes.
  • Percutaneous Biliary Procedures: 14 new bundled codes (47531 – 47544) — The guidelines provide instructions for internal and external drainage and stent placement, dilation, biopsy and removal of calculi, and injections procedures.
  • Percutaneous Image-Guided Sclerotherapy of Fluid Collection (49185) — These components are now included as part of the sclerotherapy.

The Neurological Surgery section included new and revised codes, and additional use instruction.

  • Revised codes: 37184, 37185, 37186, and 37211
  • New codes: 61645, 61650, and 61651 (endovascular therapy)

The General Surgery area underwent revisions in three areas:

  • Catheter Drainage were revised to report specific drainage sites (49405 – 49407)
  • Anal Surgery Guidelines (46020 – 46942)
  • Mediastinoscopy/Lymph Node Biopsy (new codes: 39401 and 39402)

New codes have been introduced in the Pain Medicine and Anesthesia section. Three codes have been developed to identify paravertebral block (injections) at single or multiples levels. These new codes are 64461, 64462, and 64463.

The term “film” has been replaced by the word “image” for Radiation Oncology codes. In many cases, the dosimetry calculations are now included in the radiation therapy procedures. The radiation section describing interstitial radiation source applications (placing of seeds) has been revised. A new code structure for radiation therapy has been delayed for another year. The CMS-created G-codes (G6001-G6016) will be continued for 2016.

There are nine new codes and three revised codes in the Molecular Pathology section. Gene names have been updated using the Human Genome Organization (HUGO) approved names. Six codes that were a Tier 2 molecular pathology code have moved to Tier 1, as the procedures were performed with frequencies consistent with their intended clinical use. Tier 2 procedures were revised to include the addition of analytes, revised analyte names, and deleted analytes.

Non-Molecular Pathology code revisions include:

  • Immunofluorescent/immunohistochemistry Studies
  • Obstetric Panel
  • Chemistry: Chromatography and Mass Spectometry
  • Serology
  • Microbiology

A small number of changes were made to the following areas:

  • Ophthalmology
    • Corneal Surgery (65785)
    • Laser Trabeculoplasty (65855)
    • Repair of Retinal Detachment (67107 – 67113)
    • Destruction of Retinopathy (67227 – 67229)  
  • Otolaryngology
    • Vestibular Function Tests (new code 92537 and 92538)
    • Cerumen Impaction Removal (new code 69209 and 69210)  
  • Gastroenterology
    • Esophageal Fundoplasty (new code 43210)
    • Esophageal Balloon Distension Study (revised code 91040)
    • Liver Elastography (91200) — Evaluation and management codes can be reported on the same day as this service. This service is placed on the New Technology list and will be re-reviewed by the RUC in three years.  
  • Cardiovascular
    • Five new codes for Transcatheter Leadless Pacemaker Insertion (0387T, 0388T, 0389T, 0390T, and 0391T)
    • Transcatheter Pulmonary Valve Implantation now has a category I code: 33477
    • Myocardial Strain Imaging has a new category III code: 0399T  
  • Radiology
    • The term “film” has been replaced with the term “image”
    • Spinal x-ray codes have been revised and further defined by the number of views
    • Hip, pelvis, and femur x-rays have been revised
    • Soft Tissue Localization Marker Placement has new codes (10035 and 10036) and imaging guidance is bundled

How we can help

The 2016 CPT code changes were discussed at great detail at the symposium — this article offers only a snapshot. The operational and financial complexities of these changes could impact organizations significantly, depending on the services they provide and their level of understanding of these changes. Some of these changes, such as the transition and chronic care management codes, present opportunities to improve reimbursement. Others could strain reimbursement if they are not implemented correctly and monitored closely.

CLA has assisted a variety of organizations in understanding the impact of these changes, as well as taking advantage of new and emerging reimbursement opportunities these changes create. CLA can help you understand these coding changes, and guide your organization as you adapt.