An overview of 1999 CPT code changes

By Rita A. Scichilone, MHSA, RRA, CCS, CCS-P
Professional Management Midwest
Omaha, NE

It’s that time of year when revised CPT code books have rolled off the presses and health care organizations gear up for changes in coding and reimbursement processing of patient services.

The 1999 version of CPT contains additions, deletions, and revised to code descriptions.

Two new appendices were added to show which codes are considered "add-on codes" (Appendix E) and which codes are exempt from modifier -51 use (Appendix F). (For ordering information, see resource box, below right.)

Add-on codes cannot stand alone since they are intended to be additional, rather than primary, procedures. For example, the first one on the list is CPT code 11101, now marked with a plus symbol and a description of "each separate/additional lesion (list separately in addition to code for primary procedure)." The primary procedure in this case is 1110 — Biopsy of skin, subcutaneous tissue, and/or mucous membrane (including simple closure), unless otherwise listed (separate procedure); single lesion.

As you can see, code 11101 would not stand alone. It would only be used when more than one biopsy of the skin was performed. Modifier -51 would not be appended since, by definition, it is an add-on code. To make sure coders understand, the manual provides instructions to "use 11101 in conjunction with code 11100."

Many of the revised descriptions in the 1999 version of CPT include similar language to clarify when you should report additional codes separately. Last July, Medicare implemented the use of hospital-specific modifiers. Two of the modifiers, -52 and -53, had descriptions from the Health Care Financing Administration (HCFA) that were at variance from the CPT definition.

The 1999 version of CPT makes it easier to distinguish hospital-reported modifiers by creating a special section titled Modifiers Approved for Ambulatory Surgery Center (ASC) Hospital Outpatient Use. It is interesting to note that two modifiers were created so the CPT definitions can remain constant. Modifiers -73 and -74 have been added to CPT with the HCFA definitions. The new language follows:

-73 Discontinued Outpatient Hospital/ Ambulatory Surgery Center (ASC) Procedure Prior to the Administration of Anesthesia: Due to extenuating circumstances or those that threaten the well-being of the patient, the physician may cancel a surgical or diagnostic procedure subsequent to the patient’s surgical preparation (including sedation when provided, and being taken to the room where the procedure is to be performed), but prior to the administration of anesthesia (local, regional block[s], or general).

Under these circumstances, the intended service that is prepared for, but canceled, can be reported by the usual procedure number and the addition of modifier -73 or by use of the separate five-digit modifier 09973. Note: The elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported.

For physician reporting of a discontinued procedure, see modifier -53.

-74 Discontinued Outpatient Hospital/ ASC Procedure After the Administration of Anesthesia: Due to extenuating circumstances or those that threaten the well-being of the patient, the physician may terminate a surgical or diagnostic procedure after the administration of anesthesia (local, regional block[s], or general) or after the procedure was started (incision made, intubation started, scope inserted, etc).

Under these circumstances, the intended service that is started but terminated can be reported by the usual procedure number and the addition of modifier -74 or by use of the separate five-digit modifier 09974. Note: The elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported. For physician reporting of a discontinued procedure, see modifier -53.

Modifier -53 does not appear in this listing; it is now restricted to physician use only. Modifier -52 for reduced services is listed as a hospital modifier. The language in 1999 CPT follows:

-52 Reduced Services: Under certain circumstances, a service or procedure is partially reduced or eliminated at the physician’s discretion. Under these circumstances, the service provided can be identified by its usual procedure number and the addition of modifier -52.

Note: For hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or canceled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers -73 and -74.

It is not clear under which circumstances modifier -52 would be used since HCFA regulations include anesthesia as the determining factor for reduced services. It could be assumed that hospitals would use these modifiers only on occasions when services were reduced and the use of anesthesia would not apply, such as radiology. It should be noted that the use of five digits to communicate modifiers is not permitted for HCFA patients. The directive requires use of the two-digit modifiers appended to the CPT codes on the UB-92.

For the first time in CPT history, HCPCS modifiers have been added to Appendix A in the ASC/Hospital section. This is a list of the approved national modifiers required by HCFA for reporting after July 1, 1998. This is not a complete list, since only hospital modifiers are included, rather than the full set used by other types of health care providers.

The most recent draft of the revised Evaluation and Management (E&M) Documentation Guide lines is available on the American Medical Association’s World Wide Web site: www.ama-assn.org. These guidelines may be used by hospital outpatient departments or hospitals in the ambulatory payment classification (APC) system to determine appropriate levels of E&M code selection and corresponding payment.

These documentation guidelines are not applicable to the Preventive Medicine Services, Critical Care, or Neonatal Intensive Care codes. Any format for documenting history (including preprinted history forms completed by the patient and reviewed by the physician) is acceptable. The chief complaint and reason for the encounter requirements are not applicable to inpatient hospital services. Definitions of chief complaint, reason for encounter, and brief/extended history of present illness have been added.

Some health information management professionals involved in current auditing for documentation to support coding levels believe the revised documentation guidelines will be easier to apply than the current ones.

At this point, no date of implementation or application for these guidelines for audit by Medicare has been offered. Currently, the 1995 or 1997 guidelines are used, whichever most benefits the health care provider.