Health Information Management

Review guideline changes as well as CPT code updates

JustCoding News: Outpatient, December 14, 2011

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Coders know to go through CPT® code changes each year, but they shouldn’t overlook the importance of reviewing the guideline changes as well.

The guidelines are important because not only do they offer clarity regarding how to use the codes, but so many payer coding rules come straight from the guidelines. The guidelines are a huge driving force for why the Correct Coding Initiative (CCI) edits exist, says Peggy S. Blue, MPH, CPC, CCS-P, regulatory specialist for HCPro, Inc., in Danvers, MA, and an AHIMA-certified ICD-10 trainer.

The green text in the CPT book indicates material that is new to the book this year, whether it’s a change or additional information. Coders need to understand what changed this year from the previous year.

“The number of changes that occur every year underscore why it is so important to buy a new CPT book every year,” Blue says. “Go look at Appendix B, which is the summary of additions, deletions, and revisions. Notice the [American Medical Association (AMA)] doesn’t make a handful of changes—they make a couple of hundred changes. If you don’t have the current year’s book, you’re working at a disadvantage.”

Evaluation and management guideline changes
The AMA made a significant change to the 2012 guidelines for distinguishing between new and established patients when reporting evaluation and management (E/M) professional services.

According to the guidelines for 2012, a new patient is one who had not received any professional services from a physician or another physician in the exact same specialty and the exact same subspecialty in the same group practice within the past three years. In the past, the guidelines referred just to a physician in the same specialty in the same group practice.

Consider this example: A 17-year-old patient sees an oncologist in a particular group and then sees a pediatric oncologist in the same group. The patient would be a new patient of the pediatric oncologist because the physician is in a different subspecialty, says Shelley C. Safian, PhD, MAOM/HSM, CCS-P, CPC-H, CHA, of Safian Communications Services in Orlando, FL, and an AHIMA-certified ICD-10 trainer.
The AMA included a decision tree on p. 5 of the 2012 CPT Manual as a tool to help coders determine whether a patient is new or established.

Integumentary system guideline changes
The AMA made a slight revision to the guidelines for wound debridement by adding the words “as appropriate” to the guidelines for cases in which the physician debrides four wounds for a single patient on the same day. The guideline now reads: “If all four wounds were debrided on the same day, use modifier -59 [distinct procedural service] with either 11042 or 11044 as appropriate.”

Coders will also find additional clarifications under the guidelines for complex repairs. When a physician repairs more than one classification of wound, coders should report the most complicated procedure as the primary procedure and report the less complicated procedure as secondary with modifier -59.

In addition, when nerves, blood vessels, and tendons are involved, coders should report the repair under the appropriate system (e.g. nervous, cardiovascular, or musculoskeletal). Repair of these wounds is included in the primary procedure unless a complex repair is required, in which case, coders should use modifier -59.

In the 2011 guidelines, the AMA instructed coders to report modifier -51 (multiple procedures), Safian says. “So this is a change not to the code itself, but which modifier should be used.”

The AMA also included lengthy definitions under the skin replacement surgery subsection. The guidelines now define codes 15002–15005 for skin replacement surgery as the initial services for preparing a clean, viable wound surface for placement of a graft, skin substitute, flap, or negative pressure wound therapy.

The guidelines also state that the harvest or application of an autologous skin graft is included in the codes for autologous/tissue cultured autografts. However, coders should report the repair of the donor site separately.

When a physician applies a non-graft wound dressings or injects skin substitutes, coders should not report codes for non-autologous skin grafts, non-human skin substitute grafts, and biological products that form a scaffolding for skin growth.

Respiratory system guideline changes
Coders will find significant new guidelines for reporting lung and pleural biopsies in the respiratory section under the lungs and pleura subsection.

The AMA has not updated this chapter of codes since the 1990s, says Christi Sarasin, CCS, CCDS, CPC-H, FCS, principal of the Sarasin Consulting Group in Friendship, MD, and AHIMA-certified ICD-10 trainer. Take time to read the guidelines because they are very involved, she adds.

The new guidelines define different procedures in this section and provide instruction for how to select the appropriate codes. In the guidelines, the AMA defines:

  • The different approaches that physicians may use for lung procedures
  • The amount and type of tissue that the physician may remove
  • The difference between diagnostic or therapeutic procedures
  • The ways the physician may perform the various removal procedures

The guidelines also more distinctly identify wedge resections by stating, “A therapeutic wedge resection requires attention to margins and complete resection even when the wedge resection is ultimately followed by a more extensive resection.”

When a physician uses intra-operative pathology consultation to determine that he or she must perform a more extensive resection at the same anatomical site, coders should report the wedge resection as a diagnostic wedge resection (CPT codes 32507 and 32668). If no more extensive resection is needed, coders should report the procedure as a therapeutic wedge resection (CPT codes 32505 and 32666).

Cardiovascular guidelines changes
In the cardiovascular section, the AMA included extensive instruction under the pacemaker or pacing cardioverter-defibrillator section. The new guidelines define what is included in a cardioverter-defibrillator as well as what is involved in the various procedures.

Coders will also find a table that clarifies which codes they should report for pacemakers and which to report for implantable cardioverter-defibrillators. “It’s important to note with that table that the introductory language and the code descriptions are going to supersede the information in that table in the event of any inconsistencies,” says Sarasin.

The AMA also included additional guidelines under the cardiac arrest subsection. In addition, the AMA provides clarification for the codes for endovascular repair of an iliac aneurysm to include a more appropriate code range (e.g. 36200, 36245–36248) for the introduction of guide wires and catheters.

Under the Intra-arterial—Intra-aortic subsections, coders will find new guidelines for diagnostic studies of arteriovenous (AV) shunts for dialysis to clarify reporting for codes 36147 and 36215. In addition, new guidelines for interventions for AV shunts created for dialysis clarify reporting for codes:

  • 35475–35476
  • 36011–36012
  • 36147–36148
  • 36870
  • 37204–37206
  • 75960
  • 75962
  • 75978

New guidelines under the endovascular revascularization subsection clarify the specific type of closures included for lower extremity endovascular procedures. Additional guidelines explain that pressure application of an arterial closure device or standard closure of a puncture site by suture is included as part of the procedure. The guidelines also specify services that coders should report separately, such as extensive repair or replacement of an artery (CPT code 35226 or 35286).

E-mail your questions to Senior Managing Editor Michelle A. Leppert, CPC-A, at To learn more about the CPT changes for 2012, order an on-demand copy of HCPro’s December 6 audio conference, CPT 2012: Overview of Major Code Changes.

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