New CPT codes contain over 600 changes

Coders must learn to use two new symbols

As of Jan. 1, there are some 600 changes in the newly released CPT codes that coders—and those dealing with codes in your practice—are going to have to incorporate into their operations.

Coding and billing staff take note: Odds are not all third-party payers are going to be geared up to immediately start using these new codes come New Year’s Day. Therefore, the smart bet is to check with payers and carriers beforehand to see what their own internal timetable is for implementing the new codes.

The new CPT changes break down like this: 468 existing codes have been revised, 40 codes deleted, and 157 new codes added. Of the revisions, the majority (269) can be found in the Musculoskeletal System section.

Besides these code changes, practices are going to have to contend with a series of some 500 so-called "black box" commercial edits contained in the claims review software of Atlanta-based HBO & Company, (HBOC) an outside vendor selected by HCFA to check provider claims for accuracy and medical necessity.

The plan had been to add these edits to a file maintained by the Correct Coding Initiative. However, HBOC objected, saying the edits are its private, proprietary property and cannot be released to the public. That’s why they are called "black box" edits: The claims go in and the denials come back, but there is no explanation of why they were denied because the decision-making process is proprietary.

In turn, practices will need to keep an extra-close track on any denials so they can separate commercial edits from the regular HCFA edits.

Various medical and specialty groups are negotiating with HCFA to work out a compromise on this "black box" issue. Meanwhile, the best thing to do is stay in close contact with your Medicare carriers, who will handle any denials.

Black boxes aside, the most dramatic change in the CPT was the American Medical Association’s addition of new symbols to the coding system. Specifically, a plus sign (+) now denotes an "add on" code, and a circle with a line across it (Ø) signifying that is a modifier -51 exempt code.

Coders should note many of the 1999 code descriptions also include the instruction "List separately in addition to code for primary procedure" to help denote a new or add-on code. "This helps clarify reporting requirements," says Rita Scichilone, a coding and reimbursement consultant with Professional Management Midwest in Omaha, NE, and Physician Payment Update’s resident coding columnist. For example, if more than one breast lesion is localized for biopsy, physician codes 19290 and 19291 would both be reported, and modifier -51 would not be added to the second procedure. Code 19290 is for the first lesion placement on the needle localization wire, and code 19291 is assigned for each subsequent placement during the same procedure episode.

For the new codes exempt from modifier -51 reporting, these codes may not have "each" or "each additional" within the CPT descriptions.

For example, code 17004 is one of the codes that caused confusion in reporting destruction of skin lesions. The previous issues of the CPT manual showed this code indented under the main code of 17000. Some coders would assign 17000 for the first lesion, code 17003 for the 2nd through 14th lesions, and then report code 17004 in addition for the lesions over 15 removed during a single episode. The revised terminology clarifies this as a separate code and provides these instructions: "Do not report 17004 in conjunction with 17000-17003." Some of the codes on this list will have terminology that reflects stages or other conditions that imply they would not qualify as multiple procedures subject to reduction in reimbursement policies by third-party payers.

Modifier listings have been moved to Appendix A at the back of the manual and do not appear in front of all individual sections of CPT, as they have previously, points out Scichilone.

"Physician coders will be pleased at the clarification provided in the 1999 book for modifier -25 dealing with Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service,’" says Scichilone.

The new clarifying language in the description reads as follows: "The E/M service may be prompted by the symptom or condition for which the procedure and/or the service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date."

While third-party payers still will require documentation to support billing two service codes for the same encounter, this E/M change may help in obtaining reimbursement for an office visit and a procedure on the same day, particularly when the procedure has not been scheduled ahead of time, says Scichilone.

Other changes include additional language to preventive medicine service codes involving modifier -25 to report separate services provided during the same encounter. The 1999 version of CPT also explains that the comprehensive examination within the code range 99381-99397 is not the same as the "comprehensive" examination requirements for Evaluation and Management codes.

Also, a section has been added for hospital outpatient and ambulatory surgery center-designated modifiers to clarify reduced or discontinued procedure reporting, as required by the Health Care Financing Administration. "For the first time, CPT has also listed selected HCPCS modifiers for easy reference," says Scichilone. "These are only the HCPCS modifiers that apply to hospital reporting. For a complete set of HCPCS modifiers, a HCPCS manual must be consulted."