The new CPT codes are out! Will they lead to less hassle, more payments?
Coding clarity and specificity are this year’s goals, experts say
Ambulatory surgery coders came up big winners in the latest CPT coding sweeps. The 1997 revisions to the Physicians’ Current Procedural Terminology manual lists more than a dozen important additions and deletions to the surgery section that go a long way in clarifying codes for several complex procedures. The revisions should make work that much easier for facility-based health information management (HIM) professionals.
Important, though less extensive, modifications also were made in radiology, pathology, and noninvasive vascular studies.
Overall, this year’s changes appear to be an attempt to clear up ambiguities within several major surgery codes, including laparoscopies and musculoskeletal repairs and resections, and their descriptors.
HIM experts lauded the change as a reflection that the Chicago-based American Medical Association (AMA), which publishes the CPT handbook and revises it annually, wants earnestly to demystify a coding system often thought by hospital personnel to be complex.
"In the past five years, the AMA has been working hard to bring clarity and specificity to the CPT [codes], especially to those of us who work outside physician specialties," says Lora DeWald, RRA, CCS, vice president of HIM with Presentation Health System in Sioux Falls, SD.
Changes reflect growing trend
In overall magnitude, this year’s changes are comparable to past revisions. What’s noteworthy, however, is the growing trend of focusing on intricate surgeries, which continue shifting from the inpatient to the outpatient setting, DeWald says.
The changes should bring coders and third-party payers closer to agreement on dozens of coding situations. For years, many of the claims associated with these codes have been mired in endless disputes and rejections, DeWald says. However, "whether these new additions and deletions will result in any better payment to outpatient providers remains to be seen," she adds.
Outlined below are revisions likely to affect most ambulatory facilities and their potential impact on coders: (For a reference to a complete listing of 1997 changes, see source box, p. 3.)
1. Add-on codes.
New explanatory notes in the surgery guidelines regarding add-on codes have been written to delineate between procedures that are regarded as additional and those that are considered multiple.
"The addition of these notes clarifies that certain codes in CPT are considered add-on’ codes and are exempt from the Multiple Procedure concept and the use of the modifier -51 [for physician coders]."1
Examples of these add-on codes abound in the manual and can be easily identified by the phrasing "each additional" or by the parenthetical notation (listed separately in addition to primary procedure).
"Many technicians were confused about using these codes properly," explains Sue Prophet, RRA, CCS, director of classification and coding with the American Health Information Management Association in Chicago.
Add-ons already have their original relative weights and reimbursement values set at a lower level and should not be used with a modifier, Prophet says. A modifier exposes the code to further reduction in payment or outright rejection as incorrect.
Facility coders typically don’t use modifiers, but the issue is important because a growing number of hospital and ambulatory surgery center (ASC) coders also are documenting for physician fees.
2. Open fractures and/or dislocations.
Three new codes have been added to identify the debridement of open fractures and/or dislocations. Codes 11010, 11011, and 11012 specify the removal of foreign material associated with these injuries. They’re designed to be used primarily for irrigation and debridement of traumatic bone, tendon, and nerve injuries.
"The only debridement codes previously used involved open wounds. The debridement of open fractures is really different," Prophet says. The new codes also reflect the growing volume of these cases presenting at hospitals and ASCs, Prophet adds.
A separate set of four debridement codes (11700, 11701, 11710, and 11711) were deleted and "collapsed" into two new codes 11720 and 11721. The deleted codes involved the manual and electric debridement of nails. In most cases, the AMA believes that the procedure involves both manual and electric debridement.
High-volume code is replaced
3. Microvascular flaps.
Prophet says one of the biggest surgical procedures affected by revisions in terms of occurrence and patient volume is the deletion of 15755 (microvascular transfer of flaps involving skin or deep tissue graft). Reflecting the trend toward more coding specificity, 15755 was deleted "because it was general and used to describe a variety of procedures."1
The code was replaced with three new codes: 15756, 15757, and 15758, which identify different types of flaps (muscle, skin, and fascial), each with accompanying microvascular anastomosis.
4. Intravascular ultrasound.
The introduction of two new codes in this section (37250 and 37251) "could very well lead to higher Medicare payments for facilities," speculates DeWald, who notes that the reverse often occurs when new surgery codes ultimately hit the eight-tiered Medicare ASC payment groups.
Facility coders will now be able to bill separately for the ultrasound component of the non-coronary intravascular vessel procedure. Previously, facilities were paid under the radiological codes 75945 and 75946, which Medicare normally reimburses on a fee-schedule basis.
From a payment standpoint, the new codes will increase Medicare payments. The 30000-series codes will represent the technical component, which is typically cost-based while the 70000-series will continue to reflect the lower, fee schedule-based payment. Because the new codes are add-ons, providers will be able to submit both sets to Medicare for reimbursement.
"Whatever Medicare dollar values were placed on the original codes will now inevitably increase," DeWald says.
Reference
1. American Medical Association. Review of the 1997 CPT Coding Changes. CPT Assistant 1996; 6:1-19.
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