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20-20 vision: 2020 CPT update features new drug implant, nerve injection and destruction codes

Here’s a good reason not to rely on CMS and the physician fee schedule for your CPT coding advice: The agency appears to be a bit confused about how to use the new musculoskeletal add-on codes for drug delivery device implant and removal.
 
In the proposed 2020 Medicare physician fee schedule, CMS states that the new codes “are intended to be typically reported with CPT codes 11981-11983, with debridement or arthrotomy procedures done primarily by orthopedic surgeons.”
 
In fact, according to the CPT 2020 ebook, released August 26, new add-on codes 20700-20705 are to be used instead of the integumentary drug delivery device implant codes.
 
The six new musculoskeletal add-on codes are among the 244 new, 72 revised and 68 deleted codes in next year’s CPT manual, according to the ebook. The 384 code changes take effect Jan. 1, 2020.
 
Codes 20700-20705 describe manual preparation and insertion of implants designed to deliver drugs, such as antibiotics, to deep musculoskeletal spaces. The implants may take the form of beads, intramedullary nails or temporary joint spacers, placed when a patient develops an infection around a joint arthroplasty, requiring its removal.
 
Coding guidance in the 2020 CPT manual includes long lists of codes that may be reported in conjunction with each of the new implant add-on codes. For example, code 20700 (Manual preparation and insertion of drug-delivery device[s], deep [eg, subfascial] [List separately in addition to code for primary procedure]) may be reported with primary procedure codes, such as open fracture debridement (11010-11012) and shoulder infection incision and drainage (23030-23044), among others. 
 
However, you are not to report code 20700 in conjunction with code 11981 (Insertion, non-biodegradable drug delivery implant), the new CPT ebook instructs.
 
Other notable code changes in the 2020 CPT manual include:
 
New dry needling codes
 
Be careful not to confuse the new codes 20560 (Needle insertion[s] without injection[s]; 1 or 2 muscle[s]) and 20561 ( …; 3 or more muscles) with existing CPT codes for trigger point injections (20552-20553) or acupuncture (97810-97814). Like the trigger point injection codes, 20560 and 20561 describe needle insertion into trigger points. But unlike the trigger point codes, no medication is administered through the needles for 20560 and 20561.
 
Note also the difference between dry needling and acupuncture: Dry needling describes needle insertion directly into muscular trigger points, while acupuncture may or may not do so.
 
Go online with E/M services
 
Your practice may want to hit the refresh button on online E/M services. As previously revealed in the proposed 2020 Medicare physician fee schedule, the 2020 CPT manual contains three new time-based codes for online E/M services, and CMS intends to cover the services: 99421 (Online digital evaluation and management service for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes), 99422 ( … ; 11-20) and 99423 ( … ; 21 or more minutes). Based on the proposed rule, CMS will continue to cover G2010 and G2012, codes that were introduced this year for brief, remote, patient-initiated check-ins.
 
The new codes will replace 99444 (Online evaluation and management service provided by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient or guardian, not originating from a related E/M service provided within the previous 7 days, using the Internet or similar electronic communications network). CMS does not cover this code.
 
The electronic version of the CPT manual provides details on the codes, including:
  • The patient must initiate the service through a HIPAA-compliant secure platform.
  • The service must include evaluation, assessment and management of the patient by a doctor or qualified health care professional (QHP). It should not be used for services such as relaying test results without an evaluation or scheduling appointments.
  • The seven-day period described in the code begins when a doctor or QHP personally reviews the patient’s inquiry.
  • A number of activities performed by any physician or QHP in the practice are included in cumulative time, such as:
  • Reviewing the initial inquiry and relevant patient records.
  • Personal interaction with clinical staff focused on a patient’s problem
  • Development of a management plan.
  • Follow-up communication with the patient.
Remote monitoring revisited
 
You’ll find two new codes for digitally-stored data services in the 2020 CPT manual:
  • 99473 (Self-measured blood pressure using a device validated for clinical accuracy; patient education/training and device calibration); and
  • 99474 ( … ; separate self-measurements of two readings one minute apart, twice daily over a 30-day period [minimum of 12 readings], collection of data reported by the patient and/or caregiver to the physician or other qualified health care professional, with report of average systolic and diastolic pressures and subsequent communication of a treatment plan to the patient).
Take note of guidelines for the codes. For example, you may not report 99473 more than once per device.
 
A remote physiological monitoring treatment management code that was introduced in 2019 will be upgraded to a primary code in 2020 and given one add-on code. The new descriptor for 99457 will be “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; first 20 minutes.” A new add-on code will describe each additional 20 minutes of service, and the CPT manual’s half-time rule will not apply to the codes. New guidelines state that providers must meet the 20-minute threshold to report the codes.
 
Pericardial drainage gets specific
 
Note what’s out next year: two pericardiocentesis codes and one tube pericardiostomy code (33010-33015) that do not include imagine guidance. And what’s in next year: codes for pericardiocentesis and percutaneous pericardial drainage with insertion of an indwelling catheter that do include image guidance. Take these details to heart for your 2020 reporting:
 
Report pericardiocentesis with 33016. A note states that the code should not be reported in conjunction with ultrasound, fluoroscopic, CT or MRI image guidance codes (76942, 77002, 77012 and 77021).
 
Pay close attention to the patient’s age and diagnosis when you report percutaneous pericardial drainage with insertion of an indwelling catheter and the clinician uses fluoroscopic or ultrasound image guidance, or a combination of image guidance techniques. Report 33017 when the patient is at least six years old and does not have a congenital cardiac anomaly. Report 33018 for patients who are five years old or younger and for patients of any age who have a congenital cardiac anomaly. The manual defines congenital cardiac anomaly as “abnormal situs … , single ventricle anomaly/physiology, or any patient in the first 90-day postoperative period after repair of a congenital cardiac anomaly.”
 
A note for the codes states they should not be reported in conjunction with image guidance codes 76942, 77002, 77012, 77021 or 75989, which describes radiological guidance with supervision and interpretation for percutaneous drainage with placement of a catheter.
 
One code for percutaneous pericardial drainage with insertion of indwelling catheter for patients who are 6 years old or older and who do not have a congenital cardiac anomaly.
 
However, you will report 33019 for all CT-guided percutaneous drainage services with an indwelling catheter. A final note to keep in mind is that indwelling catheter codes should only be reported when the catheter is left in place after the procedure.  
 
Prepare for nervous system changes
 
Spinal taps will be reported based on whether the service was performed with needle guidance in 2020. In addition, practices that report nerve blocks should take a look at the nervous system chapter section for somatic nerves when they receive their manuals. A preview of code changes in the proposed physician fee schedule alerted practices to changes to the descriptors, and some of the language in the proposed rule about the revised codes appears to have been drawn from the CPT manual. Updated guidance for codes 64400-64450 states in part that the codes “… are reported once per nerve plexus, nerve or branch as described in the descriptor regardless of the number of injections performed along the nerve plexus, nerve or branch described by the code.”
 
More details are available for the new block codes including the requirements for blocks of nerves innervating the sacroiliac joint (64451) and genicular nerves (64454). For example, you’ll report 64451 once for any number of nerves injected and you will report 64454 once when the clinician injects at least three nerve branches.
 
This is a breaking news alert. Check back regularly for updates. Visit our bookstore to order your 2020 CPT manual.
 
Blog Tags: AMA, Breaking news
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