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CPT 2019: Check the 6 new E/M codes, and don't overlook the new guidelines

You’ll find new guidance that will help practices document services, code correctly and combat denials in your 2019 CPT manual. The electronic version of the 2019 CPT manual is available and DecisionHealth has reviewed the book to create this overview of some of the revisions and additions that you’ll find.
Evaluation and Management
Say hello to a new E/M subsection for “remote monitoring” services. You’ll find a series of those codes now tucked away in the E/M section of the code book. The section contains remote-monitoring code 99091, which Medicare unbundled on Jan. 1, 2018, as well as two new codes:
  • 99453 (Remote monitoring of physiologic parameter[s] [eg, weight, blood pressure, pulse oximetry, respiratory flow rate], initial; set-up and patient education on use of equipment)
  • 99454 ( …; device[s] supply with daily recording[s] or programmed alert[s] transmission, each 30 days)
“Codes 99453 and 99454 are used to report remote physiologic monitoring services (eg, weight, blood pressure, pulse oximetry) during a 30-day period,” explains the 2019 CPT book.
Also new is the “remote physiologic monitoring treatment management services” subsection, which contains a single new code for 2019:
  • 99457 (Remote physiologic monitoring treatment management services, 20 minutes or more of clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month)
“Use 99457 for time spent managing care when patients or the practice do not meet the requirements to report more specific services,” CPT explains.
You’ll find two new “interprofessional consult” codes in 2019. Medicare plans to pay for a suite of interprofessional consultation codes on Jan. 1, and CPT adds two additional codes to the suite of services. The new codes are:
  • 99451 (Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician, including a written report to the patient’s treating/requesting physician or other qualified health care professional, 5 minutes or more of medical consultative time)
  • 99452 (Interprofessional telephone/Internet/electronic health record referral service[s] provided by a treating/requesting physician or other qualified health care professional, 30 minutes)
For 2019, CMS is proposing to pay for the consultation codes that would reimburse a treating or consulting physician when collaborating on a patient’s treatment plan. The agency said in the proposed 2019 Medicare physician fee schedule that it would unbundle four current codes — 99446-99449 — that pay a consulting physician for providing a report to the treating physician in addition to the two new codes.
Gain additional clarity on physician-led chronic care management (CCM) services. When your doctor takes the lead in performing CCM services, you’ll find a separate code to report and a nice boost in revenue per claim. Since CCM code 99490 debuted, nurses and ancillary staff could perform the work behind the code. In 2019, you can report the new code – 99491 – when your doctor does the work. CPT indicates that your non-physician practitioners can also report the service under incident-to rules.
The full code description is “CCM services, provided personally by a physician or other qualified health care professional, at least 30 minutes of physician or other qualified health care professional time, per calendar month, with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; comprehensive care plan established, implemented, revised, or monitored."
The 2019 CPT code book describes the difference between the two codes: “Code 99490 is reported when, during the calendar month, at least 20 minutes of clinical staff time is spent in care management activities. Code 99491 is reported when 30 minutes of physician or other qualified health care professional personal time is spent in care management activities.”
Surgery guidelines
Remember radiology documentation. The Surgery chapter guidelines contain a new section on imaging guidance reminding practices that radiology services must be properly documented even when imaging is an integral part of the service.
In addition, the new guidance warns practices that nonimage-guided tracking or localization – such as radar – should not be reported with radiology codes. “Imaging guidance should only be reported when an imaging modality (eg, radiography, fluoroscopy, ultrasonography, magnetic resonance imaging, computed tomography, or nuclear medicine) is used and is appropriately documented,” the new guidance states.
Integumentary system
Understand detailed guidance for fine needle aspiration biopsy (FNAB) services. Pay close attention to the guidelines for the new family of FNAB codes that consist of primary and add-on codes based on the method of image guidance the provider used and the number of lesions removed. For example, the descriptor for 10021 (Fine needle aspiration biopsy; without imaging guidance) will be revised to state “Fine needle aspiration biopsy; without imaging guidance; first lesion.” When appropriate, a provider would report a new add-on code: 10004 (Each additional lesion [List separately in addition to code for primary procedure]). Four more primary and add-on pairings will be available to report FNAB with ultrasound (10005-10006); fluoroscopy (10007-10008); computerized tomography (10009-10010) or magnetic resonance guidance (10011-10012). The guidance explains the difference between a FNAB and a core needle biopsy (CNB). The FNAB involves aspiration of material with a fine needle and cytological examination of the cells. A core needle biopsy involves obtaining a core sample with a larger bore needle and histopathologic examination of the tissue, the guidance states. Other instructions state that both primary and add-on codes should be reported once per lesion sampled during a single session. When a provider performs multiple biopsies with different imaging methods, report the appropriate primary code – and add-on codes, if appropriate – with modifier 59 (Distinct procedural service). If a provider performs FNAB and CNB on the same lesion, don’t report the image guidance for the CNB.
Look at skin biopsy method definitions. Guidance that defines the different types of skin biopsy procedures will help you select the appropriate code in 2019. Primary code 11100 (Biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed; single lesion) and add-on code 11101 (…; each separate/additional lesion [List separately in addition to code for primary procedure]) will be deleted and replaced with six new codes -- for example, 11102 (Tangential biopsy of skin [eg, shave, scoop, saucerize, curette]; single lesion) and add-on code 11103 (…, each separate/additional lesion [List separately in addition to code for primary procedure]). The definition states that the biopsy is performed “with a sharp blade, such as a flexible biopsy blade, obliquely oriented scalpel or curette to remove a sample of epidermal tissue with or without portions of the underlying dermis.” Additional new codes describe punch biopsies that include a simple closure when performed (11104-11105) and incisional biopsies, which also include a simple closure (11106-11107).
Musculoskeletal system
Look for imaging code guidance with new knee arthrography code. Arthrography code 27370 (Injection of contrast for knee arthrography) will be deleted and replaced with 27369 (Injection procedure for contrast knee arthrography or contrast enhanced CT/MRI knee arthrography). If you need help selecting the correct image guidance codes, look no further than the detailed parenthetical guidance.
When the provider uses fluoroscopic needle guidance (77002) for an enhanced computed tomography arthrography, report 77002 and 73701 (Computed tomography, lower extremity; with contrast material[s]) or 73702 (…; without contrast material, followed by contrast material[s] and further sections). If fluoroscopic needle guidance is used for an enhanced magnetic resonance arthrography use the needle guidance code and 73722 (Magnetic resonance [eg, proton] imaging, any joint of lower extremity; with contrast material[s]) or 73723 (…; without contrast material, followed by contrast material[s] and further sequences).
When the provider performs a radiographic arthrography, report 73580 (Radiologic examination, knee, arthrography, radiological supervision and interpretation).
Cardiovascular system
Pacemaker or defibrillator update. Changes to codes for leadless pacemakers are reflected in new guidance for this section of the 2019 CPT manual. Category III codes 0387T-0391T were deleted and replaced with permanent codes 33274 (Transcatheter insertion or replacement of permanent leadless pacemaker, right ventricular, including imaging guidance [eg, fluoroscopy, venous ultrasound, ventriculography, femoral venography] and device evaluation [eg, interrogation or programming], when performed) and 33275 (Transcatheter removal of permanent leadless pacemaker, right ventricular).
New guidelines state that insertion of a catheter into the right ventricle is included in the insertion, replacement or removal of a leadless pacemaker system. In addition, right heart catheterization codes 93451, 93453, 93456, 93457, 93460, 93461 and 93530-93533 should not be reported with the insertion or removal codes unless the right heart catheterization treats a condition that is “distinct from the leadless pacemaker procedure.” And when a system is removed and replaced during the same session, report 33274.
Central venous access revisions. The changes to the peripherally inserted central catheter (PICC) codes are the stars of this section, but don’t overlook guidance under the central venous access procedures subsection. The new manual now states that it is appropriate to code a PICC line when a saphenous vein is the insertion site.
In addition, you have more detailed guidance for when it is appropriate to report image guidance for central venous catheters. A provider may report fluoroscopic central venous catheter acces code 77001 or ultrasound guidance for vascular access code 76937 “when imaging guidance is used for centrally inserted central venous catheters, for gaining access to the venous entry site and/or for manipulating the catheter into final central position.” Imaging services will be bundled into PICC codes next year. The descriptors for current PICC insertion codes will be updated to state the service does not include image guidance: 36568 (Insertion of peripherally inserted central venous catheter [PICC], without subcutaneous port or pump, without imaging guidance; younger than 5 years of age) and 36569 (…; age 5 years or older). When a PICC line is placed with magnetic guidance, report one of these codes, the manual states.
Image guidance will be added to PICC replacement code 36584 (Replacement, complete, of a peripherally inserted central venous catheter [PICC], without subcutaneous port or pump, through same venous access, including all imaging guidance, image documentation, and all associated radiological supervision and interpretation required to perform the replacement). Two new insertion codes will include image guidance: 36572 (Insertion of peripherally inserted central venous catheter [PICC], without subcutaneous port or pump, including all imaging guidance, image documentation, and all associated radiological supervision and interpretation required to perform the insertion; younger than 5 years of age) and 36573 (…; age 5 years or older). Chest X-ray codes (71045-71048) or other imaging services to document the final catheter tip position are bundled into 36584 and 36572-36573. However, when the provider uses imaging but does not confirm the tip’s location, the practice should append modifier 52 (Reduced services) with the code.
Finally, if you’ve been wondering how to report a midline catheter, the manual has the answer: Use a venipuncture code (36400-36410).
Make sure staff review new documentation guidelines. The latest CPT manual updated the supervision and interpretation section of the chapter’s guidelines to clarify the information providers should capture – and auditors will expect to see – when radiology services are performed.
According to the supervision and interpretation, imaging guidance section, all imaging guidance codes require image documentation in the patient chart and a description of the image guidance in the procedure note. Radiological supervision and interpretation (RS & I) documentation must include documentation in the patient’s “permanent record” and a procedure or separate image report “that includes written documentation of interpretive findings of information contained in the images and radiologic supervision of the service.”
In addition, new text in the written reports section states that for the purposes of descriptors for imaging services, the images “must contain anatomic information unique to the patient for which the imaging service is provided.”
File away a new flu code. You’ll find a new injection code, 90689 (Influenza virus vaccine quadrivalent [IIV4], inactivated, adjuvanted, preservative free, 0.25mL dosage, for intramuscular use), for the 2018-2019 flu season. The code will be payable under Medicare beginning Jan. 1, according to a previous announcement from CMS.
Detailed definitions can speed coding. You’ll find it easier to report services such as the new adaptive behavior services, psychological testing and revised neurostimulator analysis and programing thanks to the definitions that accompany the codes. For example, the central nervous system assessments/tests section of the medicine chapter clarifies that a psychological evaluation test may include “emotional and interpersonal functioning, intellectual function, thought processes, personality, and psychopathology.” By comparison, a neurobehavioral status examination could include “acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities.” A neuropsychological testing evaluation may include “intellectual function, attention, executive function, language and communication, memory, visual-spatial function.” There is also a handy chart to help you select the appropriate codes.
For psychological test evaluations, practices will use code 96130 (Psychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member[s] or caregiver[s], when performed; first hour) and add-on code 96131 for each additional hour, when appropriate. Time-based codes will be used to report test administration and scoring, based on who scored the test:
  • 96136 (Psychological or neuropsychological test administration and scoring by physician or other qualified health care professional, two or more tests, any method; first 30 minutes)
  • 96137 (…; each additional 30 minutes [List separately in addition to code for primary procedure])
  • 96138 (… by technician, two or more tests, any method; first 30 minutes)
  • 96139 (…; each additional 30 minutes [List separately in addition to code for primary procedure])
You may perform and report administration and scoring codes on the same day as the testing and evaluation codes, but the services may be performed on different days, the manual states. Keep the services and the times separate, the manual states. Do not include time spent on evaluation services such as integration of patient data or interpretation of test results in the time for administration and scoring codes, the manual warns. This could be a risk when the same doctor or qualified health care professional administers and evaluates the test.
When a patient takes a standardized, computer-based test that is not administered by a clinician or technician, report 96146 (Psychological or neuropsychological test administration, with single automated, standardized instrument via electronic platform, with automated result only).
Add a series of adaptive behavior services and treatment to your repertoire. You’ll discover a new behavior assessment code intended to “address deficient adaptive behaviors (eg, impaired social, communication, or self- care skills), maladaptive behaviors (eg, repetitive and stereotypic behaviors, behaviors that risk physical harm to the patient, others, and/or property), or other impaired functioning,” states the CPT book. The primary assessment code is:
  • 97151 (Behavior identification assessment, administered by a physician or other qualified health care professional, each 15 minutes of the physician’s or other qualified health care professional’s time face-to-face with patient and/or guardian[s]/caregiver[s] administering assessments and discussing findings and recommendations, and non-face-to-face analyzing past data, scoring/interpreting the assessment, and preparing the report/treatment plan)
The code family also includes a supporting assessment code, 97152, which will be used to report the work of a provider working under the direction of a physician in a supporting capacity.
Also new are six codes in the range of 97153-97158, which “describe services that address specific treatment targets and goals based on results of previous assessments,” according to CPT.
The medicine section also contains multiple new psychological testing codes in the range of 96130-96146, which are in the broader subsection of “central nervous system assessments/tests.”
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