January 4, 2019
Significant changes in Current Procedural Terminology (CPT)* coding will be implemented in 2019. Notably, new codes have been established that bundle coding for imaging guidance with fine needle aspiration (FNA) and expand the number of skin biopsy codes. This article provides reporting information about the codes that are relevant to general surgery and its related specialties.
Codes 10021 and 10022 were identified as potentially misvalued by the American Medical Association (AMA)/Specialty Society Relative Value Scale Update Committee (RUC). It was determined that 10022 was reported with imaging guidance more than 75 percent of the time, and therefore imaging guidance should be bundled into the service. It also was determined that providers were reporting codes 10021 and 10022 for each pass of a needle rather than once per lesion as intended. The stakeholder specialties proposed extensive guideline and coding changes that were approved for CPT 2019.
The new CPT subsection guidelines for FNA biopsy codes provide a number of definitions and instructions for reporting. Specifically, an FNA biopsy is performed when material is aspirated with a fine needle and the cells are examined cytologically. It would be incorrect to report an FNA biopsy code for aspiration only. In contrast to an FNA biopsy, a core needle biopsy is typically performed with a larger bore needle to obtain a core sample of tissue for histopathologic evaluation.
FNA biopsy procedures may be performed with or without imaging guidance. Codes 10021 and 10004 are reported when imaging guidance is not used. Codes 10005–10012 are reported for FNA biopsy(ies) performed with imaging guidance; that is to say, imaging guidance is bundled into the codes and not separately reportable.
The set of new FNA biopsy codes may be reported only once per lesion sampled in a single session. When more than one FNA biopsy is performed on separate lesions at the same session, same day, same imaging modality, use the appropriate imaging modality add-on code for the second and subsequent lesion(s). When more than one FNA biopsy is performed on separate lesions, same session, same day, using different imaging modalities, report the corresponding primary code with modifier 59 for each additional imaging modality and corresponding add-on codes for subsequent lesions sampled. This instruction applies regardless of whether the lesions are ipsilateral or contralateral to each other, and/or whether they are in the same or different organs/structures.
When FNA biopsy and core needle biopsy both are performed on the same lesion, during the same session, on the same day using the same type of imaging guidance, do not separately report the imaging guidance for the core needle biopsy. When FNA biopsy is performed on one lesion and core needle biopsy is performed on a separate lesion, during the same session, on the same day using the same type of imaging guidance, both the core needle biopsy and the imaging guidance for the core needle biopsy may be reported separately with modifier 59. When FNA biopsy is performed on one lesion and core needle biopsy is performed on a separate lesion, during the same session, on the same day using different types of imaging, both the core needle biopsy and the imaging guidance for the core needle biopsy may be reported with modifier 59. Table 1 presents the new FNA biopsy code descriptors and relative value units (RVUs) for 2019.
Table 1. FNA biopsy
The Centers for Medicare & Medicaid Services (CMS) identified skin biopsy codes 11100 and 11101 through a screen of high expenditure services with Medicare-allowed charges of $10 million or more. CMS requested that these codes be reviewed as potentially misvalued because the services had not been reviewed since 2010. During the review of physician work, the stakeholder specialties noted that survey data displayed a bimodal distribution of responses because the code descriptions did not distinguish between different biopsy techniques used for sampling tissue. The stakeholder specialties and the AMA/RUC recommended referring codes 11100 and 11101 to the CPT Editorial Panel. For CPT 2019, codes 11100 and 11101 will be deleted and replaced by six new codes (11102–11107) that are based on the thickness of the sample and the technique used.
Codes 11102–11107 are reported when tissue is obtained solely for diagnostic histopathologic examination and is unrelated or distinct from other procedures/services provided in the same operative session. During certain surgical procedures in the integumentary system, such as excision, destruction, or shave removals, the removed tissue often is submitted for pathologic examination. However, obtaining tissue for pathology during the course of such procedures (excision, destruction, shave removal) is a routine component and is not considered a separate biopsy procedure and is not separately reported.
Partial-thickness biopsies are those that sample a portion of the thickness of skin or mucous membrane and do not penetrate below the dermis or lamina propria. Full-thickness biopsies penetrate into tissue deep to the dermis or lamina propria, into the subcutaneous or submucosal space. Sampling of stratum corneum only, by any modality (for example, skin scraping or tape stripping) does not constitute a skin biopsy procedure and is not separately reportable.
The new code set for skin biopsy defines three distinct biopsy modalities: tangential, punch, and incisional. For each modality, there is one code to report the initial biopsy, and a second code to report each additional biopsy.
A “tangential skin biopsy” (11102, 11103) is performed with a sharp blade, such as a flexible biopsy blade, obliquely oriented scalpel, or a curette to remove a sample of epidermal tissue with or without portions of underlying dermis. Biopsy by tangential technique is not considered an excision. The tangential biopsy technique may be represented by a superficial sample and does not involve the full thickness of the dermis, which could result in portions of the lesion remaining in the deeper layers of the dermis.
A “punch skin biopsy” (11104, 11105) requires a punch tool to remove a full-thickness cylindrical sample of skin. The intent of a punch biopsy is to obtain a cylindrical tissue sample of a cutaneous lesion for the purpose of diagnostic pathologic examination. Simple closure of the defect, including manipulation of the biopsy defect to improve wound approximation, is included in the service and may not be separately reported.
An “incisional skin biopsy” (11106, 11107) requires the use of a sharp blade (but not a punch tool) to remove a full-thickness sample of tissue via a vertical incision or wedge, penetrating the dermis into the subcutaneous layer. The intent of an incisional biopsy is to obtain a full-thickness tissue sample of a skin lesion for the purpose of diagnostic pathologic examination. This type of biopsy may sample subcutaneous fat, such as when performed for the evaluation of panniculitis. Although closure is usually required for incisional biopsies, simple closure may not be separately reported.
Keep in mind that codes 11102–11107 are used to report skin biopsy(ies). For a biopsy of a different structure, use the appropriate code (for example, biopsy of the lip , biopsy of the perineum [56605, 56606]). Table 2 comprises the new skin biopsy code descriptors and RVUs for 2019.
Table 2. Skin Biopsy
CMS identified code 43760, Change of gastrostomy tube, percutaneous, without imaging or endoscopic guidance, as potentially misvalued through a screen of 0-day global codes that are reported with an evaluation and management (E/M) service more than 50 percent of the time. In addition, the AMA/RUC identified 43760 through a screen of changes in the reporting specialty. Based on review of Medicare claims data and survey data, the stakeholder specialties determined that the code descriptor represented bimodal work. For CPT 2019, code 43760 will be deleted and replaced with two new codes (43762, 43763).
Gastrostomy tubes (G-tubes) may be inadvertently removed if traction is placed on the tube. Inadvertent G-tube removal is a common complication, usually occurring in combative or confused patients who pull on the tube. If the gastrostomy tract has had time to mature (for example, at least four weeks) and the G-tube has not been removed for more than four to six hours, a replacement tube may be placed through the same gastrostomy tract. Removal and replacement may also be scheduled for a clogged tube. These procedures are straightforward and reported with code 43762.
For some patients, replacing a G-tube is more complicated. For example, in a tract that has not matured or a child in whom the G-tube has been out for many hours, the tract may be difficult to access, requiring dilation and guidewires to place a new tube. Another example is a patient where gastric contents have leaked and there is maceration, ulceration, or necrosis of the surrounding skin requiring debridement and management of a larger than normal gastrostomy tract for tube replacement. Pressure necrosis of the underlying skin also complicates replacement of a G-tube. These procedures are more complex and require more physician work than the straightforward procedure and are reported with code 43763. Table 3 presents the new G-tube code descriptors and RVUs for 2019.
Table 3. Replacement of gastrostomy tube
New code 38531 has been added to the family of lymph node excision codes for CPT 2019. The typical patient requiring this procedure is a female with previously confirmed squamous cell carcinoma of the vulva that is distant from the midline. At operation, both superficial and deep node(s) are biopsied and/or excised. If the procedure is performed bilaterally, append modifier 50, Bilateral procedure. Table 4 presents the new lymph node excision descriptor and RVUs for 2019.
Table 4. Inguinofemoral node excision
According to National Comprehensive Cancer Network Guidelines,† sentinel lymph node biopsy is now an evidence-based clinical option for staging of various gynecologic cancers. In recognition of these new guidelines, the parenthetical following code 38900 has been revised to add codes for primary and staging pelvic and vulvar procedures to the current list of codes.
+38900, Intraoperative identification (eg, mapping) of sentinel lymph node(s) includes injection of non-radioactive dye, when performed (List separately in addition to code for primary procedure)
(Use 38900 in conjunction with 19302, 19307, 38500, 38510, 38520, 38525, 38530, 38531, 38542, 38562, 38564, 38570, 38571, 38572, 38740, 38745, 38760, 38765, 38770, 38780, 56630, 56631, 56632, 56633, 56634, 56637, 56640)
New Category III code 0524T, Endovenous catheter directed chemical ablation with balloon isolation of incompetent extremity vein, open or percutaneous, including all vascular access, catheter manipulation, diagnostic imaging, imaging guidance and monitoring, has been added to CPT 2019 to report catheter-directed sclerosant ablation using balloon isolation of an incompetent extremity vein. This procedure differs from existing incompetent vein treatment codes in that an inflatable balloon located at the distal tip of a catheter is used to isolate the incompetent section of vein when delivering the sclerosing agent. The new code includes all diagnostic imaging and imaging guidance performed in support of the procedure. Monitoring of vascular access and catheter manipulation also is included. CPT Category III codes are temporary codes for emerging technology, services, procedures, and service paradigms to allow data collection and are not assigned RVUs.
Code 20005, Incision and drainage of soft tissue abscess, subfascial (i.e., involves the soft tissue below the deep fascia), was identified by the AMA/RUC as potentially misvalued because the value for the code includes inpatient physician work, but the Medicare data indicate the procedure is performed less than 50 percent of the time in an inpatient setting. The stakeholder specialties determined that an incision and drainage (I&D) of a deep abscess is reportable with other more specific codes in the CPT code set. Therefore, deletion of code 20005 was approved for 2019.
Code 29581, Application of multi-layer compression system; leg (below knee), including ankle and foot, is intended to be reported for lower extremity swelling related to venous insufficiency. It is incorrect to report 29581 in conjunction with surgical treatment of incompetent veins (for example, sclerotherapy or radiofrequency vein ablation). To prevent miscoding, a parenthetical was added to the CPT code set that instructs not to report 29581 in conjunction with codes for treatment of incompetent veins (36465, 36466, 36468, 36470, 36471, 36473, 36474, 36475, 36476, 36478, 36479, 36482, and 36483) for the same extremity. It should also be noted that code 29581 should not be reported for simply wrapping the lower extremity with elastic bandages.
For CPT 2019, Appendix L has been updated to clarify the order of vessels for arterial and venous vascular branching for catheterization procedures. This model assumes the aorta, vena cava, pulmonary artery, or portal vein is the starting point of catheterization. Accordingly, branches have been categorized into first, second, third order, and beyond. Common branching patterns of typical anatomy shown in the revised chart in Appendix L are based on Gray’s Anatomy: The Anatomical Basis of Clinical Practice.‡
2019 ACS General Surgery Coding Workshops
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Chicago, IL, May 9–11
Nashville, TN, August 8–10
Learn more about correct coding at an American College of Surgeons (ACS) General Surgery Coding Workshop. Physicians receive up to 6.5 AMA PRA Category 1 Credits™ for each day of participation.
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*All specific references to CPT codes and descriptions are © 2018 American Medical Association. All rights reserved. CPT and CodeManager are registered trademarks of the American Medical Association.
†National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines). Available at: www.nccn.org/professionals/physician_gls/default.aspx. Accessed November 19, 2018. [Subscription required for viewing.]
‡Standstring S. Gray’s Anatomy: The Anatomical Basis of Clinical Practice. 41st ed. New York: Elsevier Limited; 2016.