Chargemaster Update: Code Changes for 2012
Glenda J. Schuler, RHIT, CPC, CPC-H
Updates
• Volume of changes potentially impacting the chargemaster
Code Changes
CPT
HCPCS
• New Codes
• 294
• 348
• Deleted Codes
• 101
•
• Revised
Descriptors
• 141
• TOTAL
• 536
77
• 425
2
Agenda
•
•
•
•
•
•
•
•
•
Category II
Vascular Lab
Wound
Cardiology/Card Cath Lab
Pharmacy/IVs
Physician and Pro Fees
Radiology
Laboratory/Blood Bank
Anesthesia
•
•
•
•
•
•
•
•
•
Infusion
Behavioral Health
Pulmonary/Respiratory
Supplies, Devices & DME
Neurology
Clinics
GI Lab
Rehabilitation Services
Miscellaneous
3
Potential Changes for 2012
• On Aug. 2, 2011, President Obama signed into law the Budget Control
Act of 2011 (BCA). The bill allows the president to increase the debt
ceiling by up to $2.8 trillion, but it will reduce the deficit by $2.3 trillion
over 10 years, with at least $840 billion coming from discretionary
spending cuts over the next decade.
• There are two ways the federal deficit can be cut - through "caps" on
categories of spending or through a proposed budget hammered out
by a "Super Committee" of 12 members of Congress.
4
Status Indicators
5
5
Status Indicators
Status
Indicator OPPS Payment Status
Services furnished to a hospital outpatient that are paid under a fee
schedule or payment system other than OPPS, for example: Not paid
A
under OPPS. Paid by fiscal intermediaries/MACs under a fee
schedule or payment system other than OPPS. Services are subject to
deductible or coinsurance unless indicated otherwise.
● Ambulance Services
● Clinical Diagnostic Laboratory Services (Not subject to deductible
or coinsurance.)
● Non-Implantable Prosthetic and Orthotic Devices
● EPO for ESRD Patients
● Physical, Occupational, and Speech Therapy
● Routine Dialysis Services for ESRD Patients Provided in a Certified
Dialysis Unit of a Hospital
● Diagnostic Mammography
● Screening Mammography (Not subject to deductible or
coinsurance.)
6
Status Indicators
Status
Indicator OPPS Payment Status
Codes that are not recognized by OPPS when submitted on an
B
outpatient hospital Part B bill type (12x and 13x). Not paid under
OPPS.
● May be paid by fiscal intermediaries/MACs when submitted on a
different bill type, for example, 75x (CORF), but not paid under
OPPS.
C
D
● An alternate code that is recognized by OPPS when submitted on
an outpatient hospital Part B bill type (12x and 13x) may be available.
Inpatient Procedures. Not paid under OPPS. Admit patient. Bill as
inpatient.
Discontinued Codes. Not paid under OPPS or any other Medicare
payment system.
7
Status Indicators
Status
Indicator OPPS Payment Status
Items, Codes, and Services: Not paid by Medicare when submitted on
E
outpatient claims (any outpatient bill type).
● That are not covered by any Medicare outpatient benefit based on
statutory exclusion.
● That are not covered by any Medicare outpatient benefit for
reasons other than statutory exclusion.
● That are not recognized by Medicare for outpatient claims but for
which an alternate code for the same item or service may be
available.
● For which separate payment is not provided on outpatient claims.
8
Status Indicators
Status
Indicator OPPS Payment Status
Corneal Tissue Acquisition; Certain CRNA Services and Hepatitis B
F
Vaccines. Not paid under OPPS. Paid at reasonable cost.
Pass-Through Drugs and Biologicals. Paid under OPPS; separate APC
G
payment.
Pass-Through Device Categories. Separate cost-based pass-through
H
payment; not subject to copayment.
Nonpass-Through Drugs and Nonimplantable Biologicals, Including
K
Therapeutic Radiopharmaceuticals. Paid under OPPS; separate APC
payment.
9
Status Indicators
Status
Indicator OPPS Payment Status
Influenza Vaccine; Pneumococcal Pneumonia Vaccine. Not paid
L
under OPPS. Paid at reasonable cost; not subject to deductible or
coinsurance.
Items and Services Not Billable to the Fiscal Intermediary/MAC. Not
M
paid under OPPS.
Items and Services Packaged into APC Rates. Paid under OPPS;
N
payment is packaged into payment for other services. Therefore,
there is no separate APC payment.
P
Partial Hospitalization. Paid under OPPS; per diem APC payment.
10
Status Indicators
Status
Indicator OPPS Payment Status
STVX-Packaged Codes. Paid under OPPS; Addendum B displays APC
Q1
assignments when services are separately payable.
(1) Packaged APC payment if billed on the same date of service as a
HCPCS code assigned status indicator “S,” “T,” “V,” or “X.”
(2) In all other circumstances, payment is made through a separate
APC payment.
T-Packaged Codes. Paid under OPPS; Addendum B displays APC
Q2
assignments when services are separately payable.
(1) Packaged APC payment if billed on the same date of service as a
HCPCS code assigned status indicator “T.”
(2) In all other circumstances, payment is made through a separate
APC payment.
11
Status Indicators
Status
Indicator OPPS Payment Status
Codes That May Be Paid Through a Composite APC. Paid under OPPS;
Q3
Addendum B displays APC assignments when services are separately
payable.
Addendum M displays composite APC assignments when codes are
paid through a composite APC.
(1) Composite APC payment based on OPPS composite-specific
payment criteria. Payment is packaged into a single payment for
specific combinations of services.
(2) In all other circumstances, payment is made through a separate
APC payment or packaged into payment for other services.
12
Status Indicators
Status
Indicator OPPS Payment Status
R
S
T
U
V
X
Y
Blood and Blood Products. Paid under OPPS; separate APC payment.
Significant Procedure, Not Discounted When Multiple. Paid under
OPPS; separate APC payment.
Significant Procedure, Multiple Reduction Applies. Paid under OPPS;
separate APC payment.
Brachytherapy Sources. Paid under OPPS; separate APC payment.
Clinic or Emergency Department Visit. Paid under OPPS; separate
APC payment.
Ancillary Services. Paid under OPPS; separate APC payment.
Non-Implantable Durable Medical Equipment. Not paid under OPPS.
All institutional providers other than home health agencies bill to
DMERC.
13
Sources and References
CPT and HCPCS code changes
Sources for 2012 CPT Codes
• 2012 CPT ® Changes, An Insider’s View
• Serves as a reference tool to understanding each
of the CPT® code changes found in CPT® 2012
codebook. Every new, revised or deleted code,
text and guideline change is listed along with a
detailed rationale for the change. Immediately
know what's new, what's out (deleted) and
changed in CPT® for 2012
15
Source for 2012 CPT Coding Changes
• Appendix B
–Summary of Additions, Deletions and Revisions
• Source for all changes in today’s presentation
specific for coding changes impacting the
facility’s chargemaster
16
OPPS Payments
• APC – Ambulatory Payment Classifications
• Payments based on CPT codes reported
– No CPT code on claim means no additional payment
• Payment amounts posted on Addendum B of Medicare’s OPPS
website
• http://www.cms.gov/HospitalOutpatientPPS/AU/list.asp#TopOfPage
17
Addendum B
HCPCS
Code Short Descriptor
SI
APC
Relative
Weight
Payment Rate
National
Unadjusted
Copayment
Minimum
Unadjusted
Copayment
10022
Fna w/image
T
0004
4.5843
$315.75
$63.15
19000
Drainage of breast lesion
T
0004
4.5843
$315.75
$63.15
19100
Bx breast percut w/o image
T
0004
4.5843
$315.75
$63.15
95250
Glucose monitoring cont
V
0607
1.8654
$128.48
$25.70
99204
Office/outpatient visit new
V
0607
1.8654
$128.48
$25.70
99282
Emergency dept visit
V
0613
1.2667
$87.25
G0175
OPPS Service,sched team conf
V
0607
1.8654
$128.48
$25.70
G0248
Demonstrate use home inr mon
V
0607
1.8654
$128.48
$25.70
G0249
Provide INR test mater/equip
V
0607
1.8654
$128.48
$25.70
$20.97
$17.45
18
Source for 2012 HCPCS Coding Changes
• CMS Addendum B
– HCPCS Long Descriptions, Short Descriptions
– http://www.cms.gov/HCPCSReleaseCodeSets/ANHCPC
S/list.asp#TopOfPage
19
Appendix G – Moderate Sedation
• Summary of codes which Include Moderate
(Conscious) Sedation
–349 Codes in 2012
–320 Codes in 2011
–301 Codes in 2010
–282 Codes in 2009
20
Chargemaster 2012 and Revenue Codes
Hospitals must continue to report HCPCS codes and
charges with an appropriate UB revenue code
consistent with NUBC requirements. When reporting
the appropriate revenue code for services, hospitals
should choose the most precise revenue code, or
subcode, if appropriate. As NUBC guidelines dictate,
“It is recommended that providers use the more
detailed subcategory when applicable/available rather
than revenue codes that end in “0” (General) or “9”
(Other).”
Transmittal 1599, Effective October 1, 2008
21
Category II Codes
CPT and HCPCS code changes
Category II Codes
*IMPORTANT INFORMATION* - Updates for CPT® Category II Codes
• The American Medical Association, through the CPT Editorial Panel
and its Performance Measure Advisory Group, creates CPT Category II
codes for use as supplemental tracking codes for quality improvement
performance measures.
• The AMA publishes the latest Category II codes periodically throughout
the year - the latest Category II codes are available at the AMA Web
site (www.ama-assn.org/go/cpt) – follow the “Category II Codes” link on
the right navigation bar.
• Category II codes created after May 2011 are not included in the
publications of the CPT® 2012 codebook or the CPT® 2012 data file.
They are available at the AMA Web site.
23
Category II Codes
• Supplemental tracking codes that can be used for
performance measurements
– No new instructional notations
• Numerous code changes
– Additions
– Deletions
24
Vascular Lab
CPT and HCPCS code changes
Vascular Lab
SI
Rev
Code Ind
0920,
092X
0920,
092X
X
X
Action
DEL
ADD
2011
Code
93875
2012
Code Description
Noninvasive physiologic studies of
extracranial arteries, complete bilateral
study (eg, periorbital flow direction with
arterial compression, ocular
pneumoplethysmography, Doppler
ultrasound spectral analysis)
No recommended replacement code
Unlisted noninvasive vascular diagnostic
93998 study
26
Wound Clinic
CPT and HCPCS code changes
Wound Clinic
Rev
SI
Code Ind
0510,
051X
N
Action
ADD
2011
Code
2012
Code Description
Near-infrared spectroscopy studies of
lower extremity wounds (eg, for
0286T oxyhemoglobin measurement)
Near-infrared spectroscopy measures the percentage of hemoglobin
oxygen saturation in the microcirculation of tissue up to 3 cm below the skin.
The purpose of this study was to describe the measurable response of
normal tissue oxygenation in the leg after acute trauma with use of
this technique.
May be an opportunity for use in Vascular Lab Departments
28
Wound Clinic
Rev
Code
051X,
076X,
0420,
0430
051X,
076X,
0420,
0430
SI
2011 2012
Ind Action Code Code Description
X
NEW
X
NEW
Extracorporeal shock wave for integumentary
wound healing, high energy, including topical
0299T application and dressing care; initial wound
Extracorporeal shock wave for integumentary
wound healing, high energy, including topical
application and dressing care; each additional
wound (List separately in addition to code for
0300T primary procedure)
Effective January 1, 2012, not printed in new code book. See also
0019T, 0101T and 0102T
29
Wound Clinic – Skin Products
Rev
SI
Code Ind
2011
Code
2012
Action
Code Description
Oasis Ultra Tri-Layer Matrix, per square
DEL
C9365
centimeter
Oasis Ultra Tri-Layer Matrix, per square
NEW
Q4124 centimeter
0636
G
0636
G
0636
0636
0636
0636
0636
0636
G
K
E
E
E
E
NEW
NEW
NEW
NEW
NEW
NEW
0636
0636
0636
E
E
N
NEW
NEW
NEW
C9366
Q4122
Q4123
Q4125
Q4126
Q4127
Epifix, per square centimeter
Dermacell, per square centimenter
Alloskin RT, per square centimeter
Arthroflex, per square centimeter
Memoderm, per square centimeter
Talymed, per square centimeter
Flex HD or Allopatch HD, per square
Q4128 centimeter
Q4129 Unite Biomatrix, per square centimeter
Q4130 Strattice TM, per square centimeter
30
Cardiology/Cardiac Cath Lab
CPT and HCPCS code changes
Cardiology Services
Rev
SI
Code Ind Action
0480,
048X
S
ADD
2011
Code
2012
Code Description
Interrogation device evaluation (in person), carotid
sinus baroreflex activation system, including
telemetric iterative communication with the
implantable device to monitor device diagnostics
and programmed therapy values, with interpretation
and report (eg, battery status, lead impedance,
pulse amplitude, pulse width, therapy frequency,
pathway mode, burst mode, therapy start/stop
0272T times each day);
32
Carotid Sinus Baroreflex Activation System
33
Cardiology Services
Rev
SI
Code Ind Action
0480,
048X
S
ADD
2011
Code
2012
Code Description
Interrogation device evaluation (in person), carotid
sinus baroreflex activation system, including
telemetric iterative communication with the
implantable device to monitor device diagnostics
and programmed therapy values, with interpretation
and report (eg, battery status, lead impedance,
pulse amplitude, pulse width, therapy frequency,
pathway mode, burst mode, therapy start/stop
times each day); with programming
0273T
34
Cardiology Services
0480,
048X M
ADD
0480,
048X
S
ADD
0480,
048X
S
ADD
2012
Code Description
External electrocardiographic recording for more
than 48 hours up to 21 days by continuous rhythm
recording and storage; including recording,
scanning analysis with report, review and
0295T interpretation
External electrocardiographic recording for more
than 48 hours up to 21 days by continuous rhythm
recording and storage; recording (includes
0296T connection and initial recording)
External electrocardiographic recording for more
than 48 hours up to 21 days by continuous rhythm
recording and storage; scanning analysis with
0297T report
ADD
External electrocardiographic recording for more
than 48 hours up to 21 days by continuous rhythm
0298T recording and storage; review and interpretation
SI
Rev
Code Ind Action
0480,
048X M
2011
Code
35
Cardiac Catheterization Lab
Rev SI
Code Ind Action
0480,
048X N
DESC
0480,
048X N
DESC
2011 2012
Code Code Description
Indicator dilution studies such as dye or thermal
dilution, including arterial and/or venous
catheterization; with cardiac output measurement
93561
(separate procedure)
Indicator dilution studies such as dye or
thermodilution, including arterial and/or venous
catheterization; with cardiac output measurement
93561 (separate procedure)
36
Cardiac Catheterization Lab
Rev
SI
Code Ind Action
0480,
048X
N
DESC
0480,
048X
N
DESC
2011
Code
2012
Code Description
Indicator dilution studies such as dye or thermal
dilution, including arterial and/or venous
catheterization; subsequent measurement of
93562
cardiac output
Indicator dilution studies such as dye or
thermodilution, including arterial and/or venous
catheterization; subsequent measurement of
93562 cardiac output
37
Cardiac Catheterization Lab
Rev
SI
Code Ind Action
0480,
048X
C
ADD
2011
Code
2012
Code Description
Percutaneous transcatheter closure of the left atrial
appendage with implant, including fluoroscopy,
transseptal puncture, catheter placement(s), left atrial
angiography, left atrial appendage angiography,
0281T radiological supervision and interpretation
Effective January 1, 2012, not printed in book
38
0281T – Left Atrial Appendage
•
Left atrial appendage is a part of
the upper chamber of the
heart (left atrium). It has the
shape of a pouch and is the
place where 90% of clots can be
formed in conditions where
there is irregular blood flow.
Closure of the left atrial
appendage could prevent the
formation of small clots and
protect from stroke
39
0281T – Left Atrial Appendage
•
• The Watchman (Atritech) is a
device that closes off the left
atrial appendage (LAA) to
minimize the risk of stroke. It
is one of several techniques
for closing off the left atrial
appendage as an alternative
to Coumadin or warfarin.
Other techniques include
removing or clamping off the
left atrial appendage during
surgery
40
Cardiac Catheterization Lab
Rev
Code
SI
Ind Action
0480,
048X
N
ADD
0480,
048X
N
ADD
2011
Code
2012
Code Description
Intravascular optical coherence tomography (coronary
native vessel or graft) during diagnostic evaluation
and/or therapeutic intervention, including imaging
supervision, interpretation, and report; initial vessel
0291T (List separately in addition to primary procedure)
Intravascular optical coherence tomography (coronary
native vessel or graft) during diagnostic evaluation
and/or therapeutic intervention, including imaging
supervision, interpretation, and report; each additional
vessel (List separately in addition to primary
0292T procedure)
http://www.octnews.org/articles/2050474/lightlab-imaging-c7-xr-fd-octintravascular-imagin/
http://www.abcnews.go.com/GMA/OnCall/video/inside-heart-10698053
41
Hemodynamic monitoring
• Continuous monitoring of
movement of blood and
pressures being exerted in the
veins, arteries and chambers of
the heart.
• Invasive hemodynamic
pressure monitoring permits
continuous assessment of the
status of the critically ill patient
and their response to ongoing
therapy, providing essential
information for more precise
diagnosis and prompt
correction of a problem.
42
Cardiac Catheterization Lab
Rev
Code
0480,
048X
0480,
048X
SI
Ind Action
C
C
2011
Code
ADD
2012
Code Description
Insertion of left atrial hemodynamic monitor; complete
system, includes implanted communication module
and pressure sensor lead in left atrium including
transseptal access, radiological supervision and
interpretation, and associated injection procedures,
0293T when performed
ADD
Insertion of left atrial hemodynamic monitor; pressure
sensor lead at time of insertion of pacing cardioverterdefibrillator pulse generator including radiological
supervision and interpretation and associated
injection procedures, when performed (List separately
0294T in addition to code for primary procedure)
43
Cardiac Catheterization Lab
Transvenous Procedure Clarification Reference in 2012
code book
Provides clarification on appropriate codes to report for
pacemaker and implantable cardioverter-defibrillator
– Coding example:
– Upgrade single chamber system to dual chamber system
• Pacemaker – CPT 33233
• ICD - 33241
44
Cardiac Catheterization Lab
Rev
Code
036X,
048X
036X,
048X
036X,
048X
036X,
048X
SI
Ind Action
T
DESC
T
DESC
T
DESC
T
DESC
2011
Code
2012
Code Description
Insertion or replacement of permanent pacemaker with
33206
transvenous electrode(s); atrial
Insertion of new or replacement of permanent
33206 pacemaker with transvenous electrode(s); atrial
Insertion or replacement of permanent pacemaker with
33207
transvenous electrode(s); ventricular
Insertion of new or replacement of permanent
33207 pacemaker with transvenous electrode(s); ventricular
45
Cardiac Catheterization Lab
Rev
Code
036X,
048X
036X,
048X
036X,
048X
036X,
048X
SI
Ind Action
T
DESC
T
DESC
T
DESC
T
DESC
2011
Code
2012
Code Description
Insertion or replacement of permanent pacemaker with
33208
transvenous electrode(s); atrial and ventricular
Insertion of new or replacement of permanent
pacemaker with transvenous electrode(s); atrial and
33208 ventricular
Insertion or replacement of pacemaker pulse
generator only; single chamber, atrial or
33212
ventricular
Insertion pacemaker pulse generator only; with
33212 existing single lead
46
Cardiac Catheterization Lab
Rev
Code
036X,
048X
036X,
048X
036X,
048X
SI
Ind Action
T
DESC
T
DESC
T
ADD
2011
Code
2012
Code Description
Insertion or replacement of pacemaker pulse
33213
generator only; dual chamber
Insertion pacemaker pulse generator only; with
33213 existing dual leads
Insertion pacemaker pulse generator only; with
33221 existing multiple leads
47
Cardiac Catheterization Lab
Rev
Code
SI
Ind Action
036X,
048X T
036X,
048X SI
T
Rev
036X,
048X
036X,
048X
T
T
2011
Code
2012
Code Description
Repair of single transvenous electrode for a single
chamber, permanent pacemaker or single chamber
DESC 33218
pacing cardioverter-defibrillator
Repair of single transvenous electrode, permanent
DESC
Action 2011 33218
2012 pacemaker
Description or pacing cardioverter-defibrillator
Repair of 2 transvenous electrodes for a dual
chamber permanent pacemaker or dual chamber
DESC 33220
pacing cardioverter-defibrillator
Repair of 2 transvenous electrodes for permanent
DESC
33220 pacemaker or pacing cardioverter-defibrillator
48
Cardiac Catheterization Lab
Rev
Code
SI
Ind Action
036X,
048X
T
DESC
036X,
048X
T
DESC
2011
Code
2012
Code Description
Insertion of pacing electrode, cardiac venous system,
for left ventricular pacing, with attachment to
previously placed pacemaker or pacing cardioverterdefibrillator pulse generator (including revision of
pocket, removal, insertion, and/or replacement of
33224
generator)
Insertion of pacing electrode, cardiac venous system,
for left ventricular pacing, with attachment to
previously placed pacemaker or pacing cardioverterdefibrillator pulse generator (including revision of
pocket, removal, insertion, and/or replacement of
33224 existing generator)
49
Cardiac Catheterization Lab
Rev
Code
036X,
048X
036X,
048X
SI
Ind Action
T
DESC
Q3 DESC
2011
Code
2012
Code Description
Insertion of pacing electrode, cardiac venous system,
for left ventricular pacing, at time of insertion of pacing
cardioverter-defibrillator or pacemaker pulse generator
(including upgrade to dual chamber system) (List
33225
separately in addition to code for primary procedure)
Insertion of pacing electrode, cardiac venous system,
for left ventricular pacing, at time of insertion of pacing
cardioverter-defibrillator or pacemaker pulse generator
(including upgrade to dual chamber system and
pocket revision) (List separately in addition to code
33225 for primary procedure)
50
Cardiac Catheterization Lab
Rev
Code
SI
Ind Action
036X,
048X
T
DESC
036X,
048X
T
DESC
2011
Code
2012
Code Description
Repositioning of previously implanted cardiac venous
system (left ventricular) electrode (including removal,
33226
insertion and/or replacement of generator)
Repositioning of previously implanted cardiac venous
system (left ventricular) electrode (including removal,
33226 insertion and/or replacement of existing generator)
51
Cardiac Catheterization Lab
Rev
SI
2011 2012
Code Ind Action Code Code
036X,
048X T DESC 33233
036X,
048X T DESC
33233
036X,
048X
T
ADD
036X,
048X
T
ADD
036X,
048X
T
ADD
Description
Removal of permanent pacemaker pulse generator
Removal of permanent pacemaker pulse generator
only
Removal of permanent pacemaker pulse generator
with replacement of pacemaker pulse generator;
33227 single lead system
Removal of permanent pacemaker pulse generator
with replacement of pacemaker pulse generator; dual
33228 lead system
Removal of permanent pacemaker pulse generator
with replacement of pacemaker pulse generator;
33229 multiple lead system
52
Cardiac Catheterization Lab
Rev
Code
036X,
048X
036X,
048X
Rev
036X,
048X
036X,
048X
SI
Ind Action
2011
Code
2012
Code Description
Insertion of single or dual chamber pacing
T DESC 33240
cardioverter-defibrillator pulse generator
Insertion of pacing cardioverter-defibrillator pulse
T DESC
only; with existing single lead
SI
Action 2011 33240
2012 generator
Description
Insertion of pacing cardioverter-defibrillator pulse
T ADD
33230 generator only; with existing dual lead
Insertion of pacing cardioverter-defibrillator pulse
T ADD
33231 generator only; with existing multiple lead
53
Cardiac Catheterization Lab
Rev
Code
036X,
048X
036X,
048X
Rev
036X,
048X
036X,
048X
036X,
048X
SI
Ind Action
2011
Code
2012
Code Description
Subcutaneous removal of single or dual chamber
T DESC 33241
pacing cardioverter-defibrillator pulse generator
Removal of pacing cardioverter-defibrillator pulse
T DESC
only;
SI
Action 2011 33241
2012 generator
Description
Removal of pacing cardioverter-defibrillator pulse
generator with replacement of pacing cardioverterT ADD
33262 defibrillator pulse generator; single lead system
Removal of pacing cardioverter-defibrillator pulse
generator with replacement of pacing cardioverterT ADD
33263 defibrillator pulse generator; dual lead system
Removal of pacing cardioverter-defibrillator pulse
generator with replacement of pacing cardioverterT ADD
33264 defibrillator pulse generator; multiple lead system
54
Cardiac Catheterization Lab
Rev
Code
036X,
048X
036X,
048X
SI
Ind Action
T
DESC
Q3 DESC
2011
Code
2012
Code Description
Insertion or repositioning of electrode lead(s) for single
or dual chamber pacing cardioverter-defibrillator and
33249
insertion of pulse generator
Insertion or replacement of permanent pacing
cardioverter-defibrillator system with transvenous
33249 lead(s), single or dual chamber
55
Cardiac Catheterization Lab
Rev
Code
036X,
048X
SI
Ind Action
B
NEW
2011
Code
2012
Code Description
Insertion or replacement of a permanent pacing
cardioverter-defibrillator system with transvenous
lead(s), single or dual chamber with insertion of
pacing electrode, cardiac venous system, for left
G0448 ventricular pacing
56
Pharmacy and IV
CPT and HCPCS code changes
Pharmacy and IVs
2011 2012
SI
Rev
Description
Code Ind Action Code Code
Anthrax vaccine, for subcutaneous use
0250 E DESC 90581
Anthrax vaccine, for subcutaneous or
90581 intramuscular use
0250 E DESC
58
Pharmacy and IVs
Rev
Code
SI
2011
Ind Action Code
0250
E
0250
E
2012
Code
Description
Meningococcal conjugate vaccine, serogroups
C & Y and Hemophilus influenza b vaccine,
tetanus toxoid conjugate (Hib-MenCY-TT), 4dose schedule, when administered to children
DESC 90644
2-15 months of age, for intramuscular use
Meningococcal conjugate vaccine, serogroups
C & Y and Hemophilus influenza b vaccine
(Hib-MenCY), 4-dose schedule, when
administered to children 2-15 months of age,
DESC
90644 for intramuscular use
59
Pharmacy and IVs
Rev
Code
0636
Rev
0636
SI
2011
Ind Action Code
L
SI
L
2012
Code
Description
Influenza virus vaccine, pandemic formulation,
DEL
90663
H1N1
No replacement provided
Action 2011 2012
Description
Influenza virus vaccine, split virus, preservativeADD
90654 free, for intradermal use
CPT 90663 listed as deleted in Appendix B
Transmittal #2174, effective 4/1/11 listed both CPT 90470 and 90663 as
deleted, effective 1/1/2011
60
Pharmacy and IVs
Rev
Code
0636
SI
2011
Ind Action Code
G
0636 G
Rev
SI
0636 G
0636 G
DEL
C9270
2012
Code
Description
Injection, immune globulin (Gammaplex),
intravenous, Non-lypholized (e.g. Liquid) 500mg
Injection, immune globulin (Gammaplex),
NEW
J1557 intravenous, Non-lypholized (e.g. Liquid) 500mg
Action 2011 2012
Description
DEL
C9272
Injection, denosumab, 1 mg
NEW
J0897 Injection, denosumab, 1 mg
61
Pharmacy and IVs
Rev
Code
SI
2011
Ind Action Code
0636
G
0636
Rev
0636
0636
G
SI
G
G
DEL
2012
Code
Description
C9274
Crotalidae polyvalent immune fab (Ovine), 1 vial
Injection, Crotalidae Polyvalent Immune Fab
NEW
J0840 (Ovine) Up to 1 gram
Action 2011 2012
Description
DEL
C9276
Injection, cabazitaxel, 1 mg
NEW
J9043 Injection, cabazitaxel, 1 mg
62
Pharmacy and IVs
Rev
Code
SI
2011
Ind Action Code
0636
G
0636
Rev
0636
0636
2012
Code
Description
DEL
C9277
G
SI
Injection, alglucosidase alfa (Lumizyme), 1 mg
Injection, alglucosidase alfa (Lumizyme), 10
NEW
J0221 mg
Action 2011 2012
Description
G
G
DEL
NEW
C9280
Injection, eribulin mesylate, 1 mg
J9179 Injection, eribulin mesylate, 0.1 mg
63
Pharmacy and IVs
Rev
Code
0636
0636
Rev
0636
0636
SI
Ind
G
G
SI
G
G
2011 2012
Action Code Code
DEL
C9281
Injection,
NEW
J2507 Injection,
Action 2011 2012
DEL
C9282
Injection,
NEW
J0712 Injection,
Description
pegloticase, 1 mg
pegloticase, 1 mg
Description
ceftaroline fosamil, 10 mg
ceftaroline fosamil, 10 mg
64
Pharmacy and IVs
Rev
Code
0636
0636
Rev
0636
0636
Rev
0250,
0636
0250,
0636
SI
Ind
G
G
SI
G
G
SI
N
2011 2012
Action Code Code
Description
DEL
C9283
Injection, acetaminophen, 10 mg
NEW
J0131 Injection, acetaminophen, 10 mg
Action 2011 2012
Description
DEL
C9284
Injection, ipilmumab, 1 mg
NEW
J9228 Injection, ipilmumab, 1 mg
Action 2011 2012
Description
Hypertonic saline solution, 50 or 100 mEq, 20
DEL
J7130
cc vial
N
NEW
J7131 Hypertonic saline solution, 1 ml
65
Pharmacy and IVs
Rev
Code
0250
0250,
0636
0250,
0636
Rev
0636
0636
SI
2011
Ind Action Code
E
G
G
SI
G
G
2012
Code
Description
Injection, von Willebrand factor complex
DEL
J7184
(human), Wilate, per 100 IU VWF:RCo
Injection, von Willebrand factor complex
DEL
Q2041
(human), Wilate, per 1 IU VWF:RCo
Injection, von Willebrand factor complex
NEW
J7183 (human), Wilate, 1 IU VWF:RCo
Action 2011 2012
Description
DEL
Q2040
Injection, incobotulinumtoxin A, 1 unit
NEW
J0588 Injection, incobotulinumtoxin A, 1 unit
66
Pharmacy and IVs
Rev
Code
SI
2011
Ind Action Code
0250,
0636
N
DEL
0250,
0636
N
NEW
2012
Code
Description
Ondansetron HCl 8 mg, oral, FDA approved
prescription antiemetic, for use as a complete
therapeutic substitute for an IV antiemetic at
the time of chemotherapy treatment, not to
Q0179
exceed a 48-hour dosage regimen
Ondansetron HCl 1 mg, oral, FDA approved
prescription antiemetic, for use as a complete
therapeutic substitute for an IV antiemetic at
the time of chemotherapy treatment, not to
Q0162 exceed a 48-hour dosage regimen
67
Pharmacy and IVs
Rev
Code
SI
2011
Ind Action Code
Q2042
2012
Code
Description
0636
K
DEL
Injection, hydroxyprogesterone caproate, 1 mg
0636
Rev
0636
0636
K
SI
G
G
NEW
J1725 Injection, hydroxyprogesterone caproate, 1 mg
Action 2011 2012
Description
DEL
Q2044
Injection, belimumab, 10 mg
NEW
J0490 Injection, belimumab, 10 mg
68
Pharmacy and IVs
Rev
Code
SI
2011
Ind Action Code
2012
Code
0636
G
NEW
0636
K
NEW
C9287 Injection, brentuximab vedotin, 1 mg
Injection, Alpha 1 Proteinase, Inhibitor
J0257 (Human), (Glassia), 10 mg
0250
E
NEW
0636
G
NEW
0636
K
NEW
0250
0636
M
K
NEW
NEW
Description
J2265 Injection, Minocycline Hydrochloride, 1 mg
Injection, Factor XIII (Antihemophilic Factor,
J7180 Human), 1 I.U.
Hyaluronan or derivative, Gel-One, for intraJ7326 articular injection, per dose
Mannitol, administered through an inhaler, 5
J7665 mg
J8561 Everolimus, Oral, 0.25 mg
69
Pharmacy and IV – Payment Comparisons
HCPCS
Code
J1835
J1620
J0300
J3030
J1570
J2760
J2725
J9390
J1455
J9070
J0364
J1324
J1644
J1642
Short Descriptor
Itraconazole injection
Gonadorelin hydroch/ 100
Amobarbital 125 MG inj
Sumatriptan succinate / 6 MG
Ganciclovir sodium injection
Phentolaine mesylate inj
Inj protirelin per 250 mcg
Vinorelbine tartrate inj
Foscarnet sodium injection
Cyclophosphamide 100 MG
Apomorphine hydrochloride
Enfuvirtide injection
Inj heparin sodium per 1000u
Inj heparin sodium per 10 u
SI
K
K
K
K
K
K
K
K
K
K
K
K
K
K
APC
1355
1344
1341
1374
1343
1358
1357
1412
1359
1408
1360
1361
1373
1362
2012
Payment
Rate
$372.55
$167.25
$113.08
$76.71
$66.58
$53.76
$27.03
$17.45
$14.37
$13.43
$5.12
$0.51
$0.27
$0.18
N
N
N
N
N
N
N
N
N
N
N
N
N
N
2011
Payment
Rate
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
70
Pharmacy and IV
HCPCS
Code
J2940
J3305
J8650
J9165
Short Descriptor
Somatrem injection
Inj trimetrexate glucoronate
Nabilone oral
Diethylstilbestrol injection
2012
Payment
SI APC
Rate
E
E
E
E
N
N
N
N
2011
Payment
Rate
0.00
0.00
0.00
0.00
Formerly reportable, in 2012 will not be a covered benefit for Medicare
71
Pharmacy and IVs – Payment Updates for 2012
HCPCS
Code
J1730
J1457
J9212
J0945
J2320
J9265
J2510
C9364
J0735
90476
J0515
C9362
J0630
J0834
90680
J2805
Short Descriptor
Diazoxide injection
Gallium nitrate injection
Interferon alfacon-1 inj
Brompheniramine maleate
Nandrolone decanoate 50
Paclitaxel injection
Penicillin g procaine inj
Porcine implant, Permacol
Clonidine hydrochloride
Adenovirus vaccine type 4
Inj benztropine mesylate
Implnt,bon void filler-strip
Calcitonin salmon injection
Cosyntropin cortrosyn inj
Rotovirus vacc 3 dose oral
Sincalide injection
2012
Payment
SI APC
Rate
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
K
K
K
K
K
K
K
G
K
K
K
G
K
K
K
K
2011
Payment
Rate
1.04
2.05
6.88
7.50
9.27
9.43
12.17
17.44
19.32
23.24
25.57
51.87
56.50
68.38
73.07
75.45
72
Physician/Professional Services
CPT and HCPCS code changes
Physician/Professional Services
• Clarification of new versus established patient
definitions
– Physicians belonging to same group practice:
• exact same specialty and subspecialty
– Inclusion of Decision Tree in E/M Service Guidelines
• Provided as helpful aid in determining whether to report
E/M for either new or established patient encounters
74
Physician Services – Inclusion of Time
• CPT Codes:
– 99218, 99219 and 99220
Code descriptions now inclusive of time physician spends
at patient’s bedside and on the patient’s hospital floor or
unit
30 minutes, 50 minutes, 70 minutes
75
Physician Services
Rev
Code
098X
098X
SI
2011
Ind Action Code
2012
Code Description
Prolonged physician service in the office or other
outpatient setting requiring direct (face-to-face) patient
contact beyond the usual service; first hour (List
separately in addition to code for office or other
N DESC 99354
outpatient Evaluation and Management service)
Prolonged service in the office or other outpatient
setting requiring direct patient contact beyond the
usual service; first hour (List separately in addition to
code for office or other outpatient Evaluation and
N DESC
99354 Management service)
New paragraphs added under “Prolonged Services” to clarify
use of codes containing revised descriptions
76
Physician Services
Rev
Code
098X
098X
SI
2011
Ind Action Code
2012
Code Description
Prolonged physician service in the office or other
outpatient setting requiring direct (face-to-face) patient
contact beyond the usual service; each additional 30
minutes (List separately in addition to code for
N DESC 99355
prolonged physician service)
Prolonged service in the office or other outpatient
setting requiring direct patient contact beyond the
usual service; each additional 30 minutes (List
N DESC
99355 separately in addition to code for prolonged service)
New paragraphs added under “Prolonged Services” to clarify
use of codes containing revised descriptions
77
Physician Services
Rev
Code
098X
098X
SI
2011
Ind Action Code
C DESC 99356
C DESC
2012
Code Description
Prolonged physician service in the inpatient setting,
requiring unit/floor time beyond the usual service; first
hour (List separately in addition to code for inpatient
Evaluation and Management service)
Prolonged service in the inpatient setting or
observation, requiring unit/floor time beyond the usual
service; first hour (List separately in addition to code for
99356 inpatient Evaluation and Management service)
New paragraphs added under “Prolonged Services” to clarify
use of codes containing revised descriptions
78
Physician Services
Rev
Code
098X
098X
SI
2011
Ind Action Code
2012
Code Description
Prolonged physician service in the inpatient setting,
requiring unit/floor time beyond the usual service; each
additional 30 minutes (List separately in addition to
C DESC 99357
code for prolonged physician service)
Prolonged service in the inpatient setting or
observation, requiring unit/floor time beyond the usual
service; each additional 30 minutes (List separately in
C DESC
99357 addition to code for prolonged service)
79
Physician Services
Rev
Code
096X,
098X
096X,
098X
SI
2011
Ind Action Code
2012
Code Description
Prolonged evaluation and management service before
N DESC 99358
and/or after direct (face-to-face) patient care; first hour
Prolonged evaluation and management service before
N DESC
99358 and/or after direct patient care; first hour
80
Physician Services
Rev
Code
SI
2011 2012
Ind Action Code Code Description
Prolonged evaluation and management service before
and/or after direct (face-to-face) patient care; each
096X,
additional 30 minutes (List separately in addition to
098X N DESC 99359
code for prolonged physician service)
Prolonged evaluation and management service before
and/or after direct (face-to-face) patient care; each
096X,
additional 30 minutes (List separately in addition to
098X N DESC
99359 code for prolonged service)
81
Physician Services
• Prolonged Services With Direct Patient Contact
– Direct patient contact is face-to-face and includes additional
non-face-to-face services on the patient’s floor or unit in the
hospital or nursing facility during the same session
• Codes 99354 or 99356 are used to report first hour of prolonged
service on a given date, depending on the date of service
– Office , outpatient setting, inpatient, observation
• Codes 99355 or 99357 are used to report each additional 30
minutes beyond the first hour
82
Physician Services
• Prolonged Services Without Direct Patient Contact
– Expanded definition for use of codes 99358 and 99359
• Prolonged services not involving direct (face-to-face) care in the
office or outpatient setting, nor additional unit/floor time in the
hospital or nursing facility setting
– During the same session of an evaluation and management
service that is beyond the usual physician or other qualified
healthcare professional service time
– Neonate or newborn critical care
• Transfer of services
• Referring physician/accepting physician
83
Physician Services
• Numerous code revisions for reporting “Physician Quality
Reporting System (PQRS)”
– Formerly referred to as the Physician Quality Reporting
Initiative (PQRI)
– Voluntary CMS reporting mechanism used to measure
physician quality that will be mandatory as of January 1,
2015. Eligible providers submit quality data to set
measures through approved reporting options
84
Radiology Services
CPT and HCPCS code changes
Radiology Departments Impacted:
Angiography/
Interventional &
Diagnostic
Radiology
Radiation
Oncology
CTA Combination
Codes
Nuclear Medicine
• Diagnostic Renal Angiography
• Vena Cava Filter
• Paracentesis
• Intraoperative radiation treatment delivery procedures
• Computerized Tomographic Angiography Abdomen and Pelvis combination CPT
• New Hepatobiliary system imaging codes
• Pulmonary perfusion/ventilation imaging procedure codes
86
Radiology Bundling
• Established by the Affordable Care Act, the Center for
Innovation is a new initiative in improving health care for all
Americans
– Mission is to provide better care at reduced costs through
improvement and establish partnerships with providers
and professionals
• Better health care
• Better health
• Reduce costs
• http://innovations.cms.gov/areas-of-focus/patient-care-models/bundledpayments-for-care-improvement.html
87
Radiology Bundling
• CMS initiative to bundle codes and reduce Medicare
payments for those procedures performed together greater
than 75 percent of the time
– Radiology felt first effects of bundling initiatives in 2010
• Myocardial perfusion wall motion
• Facet Joint injections
• AV shunt dialysis-catheter procedures
88
Radiology Bundling
• In 2011, bundling continued with the creation of:
– Combined CT abdomen and pelvis codes
– Atherectomy codes above the inguinal ligaments including S&I
– Lower extremity revascularization procedures
• The bundling initiative impacts all areas of medicine, it
seems radiology’s codes have collapsed into most surgical
procedures
89
Radiology Bundling
• In 2012, bundling again has expanded to include:
– CTA angiography pelvis and abdomen
– Renal Angiography
– Inferior vena cava filter
– Sacroiliac joint injections
– Abdominal paracentesis
90
Renal Angiography
Rev
Code
SI
Ind
Action
0320
Q2
DEL
0320,
036X
Q2
NEW
0320,
036X
Q2
NEW
2011
Code
2012
Code
Description
Angiography, renal, unilateral, selective (including
flush aortogram), radiological supervision and
75722
interpretation
Selective catheter placement (first-order), main
renal artery and any accessory renal artery(s) for
renal angiography, including arterial puncture and
catheter placement(s), fluoroscopy, contrast
injection(s), image postprocessing, permanent
recording of images, and radiological supervision
and interpretation, including pressure gradient
measurements when performed, and flush
36251 aortogram when performed; unilateral
Superselective catheter placement (one or more
second order or higher renal artery branches) renal
artery and any accessory renal artery(s) for renal
angiography, including arterial puncture,
catheterization, fluoroscopy, contrast injection(s),
image postprocessing, permanent recording of
images, and radiological supervision and
interpretation, including pressure gradient
measurements when performed, and flush
36253 aortogram when performed; unilateral
91
Renal Angiography
Rev
Code
SI
Ind
2011
Action Code
0320
Q2
DEL
0320,
036X
Q2
NEW
0320,
036X
Q2
NEW
2012
Code
Description
Angiography, renal, bilateral, selective (including
flush aortogram), radiological supervision and
75724
interpretation
Selective catheter placement (first-order), main
renal artery and any accessory renal artery(s) for
renal angiography, including arterial puncture and
catheter placement(s), fluoroscopy, contrast
injection(s), image postprocessing, permanent
recording of images, and radiological supervision
and interpretation, including pressure gradient
measurements when performed, and flush
36252 aortogram when performed; bilateral
Superselective catheter placement (one or more
second order or higher renal artery branches) renal
artery and any accessory renal artery(s) for renal
angiography, including arterial puncture,
catheterization, fluoroscopy, contrast injection(s),
image postprocessing, permanent recording of
images, and radiological supervision and
interpretation, including pressure gradient
measurements when performed, and flush
36254 aortogram when performed; bilateral
92
Interventional Radiology Procedures
Rev
Code
SI
Ind
0320
N
0320,
036X,
0402 T
Rev
SI
0320,
036X,
0402
T
2011
Action Code
2012
Code Description
Percutaneous placement of IVC filter, radiological
DEL 75940
supervision and interpretation
Insertion of intravascular vena cava filter,
endovascular approach including vascular access,
vessel selection, and radiological supervision and
interpretation, intraprocedural roadmapping, and
imaging guidance (ultrasound and fluoroscopy),
NEW
37191 when performed
Action 2011 2012 Description
Repositioning of intravascular vena cava filter,
endovascular approach including vascular access,
vessel selection, and radiological supervision and
interpretation, intraprocedural roadmapping, and
image guidance (ultrasound and fluoroscopy),
NEW
37192 when performed
93
Interventional Radiology Procedures
Rev
Code
SI
Ind
0320,
036X,
0402
T
2011
Action Code
NEW
2012
Code Description
Retrieval (removal) of intravascular vena cava filter,
endovascular approach including vascular access,
vessel selection, and radiological supervision and
interpretation, intraprocedural roadmapping, and
image guidance (ultrasound and fluoroscopy),
37193 when performed
94
Interventional Radiology Procedures
Rev
Code
0320,
036X,
0402
0320,
036X,
0402
0320,
036X,
0402
SI
Ind
2011
Action Code
T
DEL
T
NEW
T
NEW
2012
Code Description
Interruption, partial or complete, of inferior vena
cava by suture, ligation, plication, clip,
37620
extravascular, intravascular (umbrella device)
Insertion of intravascular vena cava filter,
endovascular approach including vascular access,
vessel selection, and radiological supervision and
interpretation, intraprocedural roadmapping, and
imaging guidance (ultrasound and fluoroscopy),
37191 when performed
37619 Ligation of inferior vena cava
95
Interventional Radiology Procedures
Rev
SI
2011 2012
Code Ind Action Code Code Description
0320,
Cons
036X N Sed
36200 Introduction of catheter, aorta
Selective catheter placement, arterial system; each
0320,
Cons
first order abdominal, pelvic, or lower extremity
036X N Sed
36245 artery branch, within a vascular family
Selective catheter placement, arterial system; initial
0320,
Cons
second order abdominal, pelvic, or lower extremity
036X N Sed
36246 artery branch, within a vascular family
96
Interventional Radiology Procedures
Rev
Code
0320,
036X
0320,
036X
SI
Ind
2011
Action Code
N
Cons
Sed
N
Cons
Sed
2012
Code Description
Selective catheter placement, arterial system; initial
third order or more selective abdominal, pelvic, or
lower extremity artery branch, within a vascular
36247 family
Selective catheter placement, arterial system;
additional second order, third order, and beyond,
abdominal, pelvic, or lower extremity artery branch,
within a vascular family (List in addition to code for
36248 initial second or third order vessel as appropriate)
97
Interventional Radiology Procedures
Rev
SI
Code Ind
0320,
0350,
036X B
0320,
0350,
036X
B
2011
Action Code
2012
Code Description
Injection procedure for sacroiliac joint,
DESC 27096
arthrography and/or anesthetic/steroid
Injection procedure for sacroiliac joint,
anesthetic/steroid, with image guidance
(fluoroscopy or CT) including arthrography
DESC
27096 when performed
Code 27096 is reported with guided imaging for fluoroscopy or CT.
If imaging guidance is not used, see 20552, Injection(s); single or
multiple trigger point(s), 1 or 2 muscle(s), reportable with 036X
revenue code
98
Interventional Radiology
Rev
Code
SI
Ind
0320
Q2
0320,
0350,
036X
B
2011
Action Code
2012
Code Description
Radiological examination, sacroiliac joint
arthrography, radiological supervision and
DEL 73542
interpretation
Injection procedure for sacroiliac joint,
anesthetic/steroid, with image guidance
(fluoroscopy or CT) including arthrography
DESC
27096 when performed
For Medicare, must report
G0259 Injection procedure for sacroiliac joint; arthrography
G0260 Injection procedure for sacroiliac joint; provision of anesthetic,
steroid and/or other therapeutic agent, with or without arthrography
99
Interventional Radiology
Rev
Code
SI
Ind
0320
N
0320
N
2011
Action Code
2012
Code Description
Fluoroscopic guidance and localization of needle or
catheter tip for spine or paraspinous diagnostic or
therapeutic injection procedures (epidural,
subarachnoid, or sacroiliac joint), including
DESC 77003
neurolytic agent destruction
Fluoroscopic guidance and localization of needle or
catheter tip for spine or paraspinous diagnostic or
therapeutic injection procedures (epidural or
DESC
77003 subarachnoid)
100
Interventional Radiology
Rev
Code
SI
Ind
0320
Q2
0320
Q2
2011
Action Code
2012
Code Description
Transluminal balloon angioplasty, peripheral artery
other than cervical carotid, renal or other visceral
artery, iliac or lower extremity, radiological
DESC 75962
supervision and interpretation
Transluminal balloon angioplasty, peripheral artery
other than renal or other visceral artery, iliac or
lower extremity, radiological supervision and
DESC
75962 interpretation
101
Interventional Radiology
Rev
Code
SI
Ind
0320
N
0320
N
2011
Action Code
2012
Code Description
Transluminal balloon angioplasty, each additional
peripheral artery other than cervical carotid, renal or
other visceral artery, iliac and lower extremity,
radiological supervision and interpretation (List
separately in addition to code for primary
DESC 75964
procedure)
Transluminal balloon angioplasty, each additional
peripheral artery other than renal or other visceral
artery, iliac or lower extremity, radiological
supervision and interpretation (List separately in
DESC
75964 addition to code for primary procedure)
102
Interventional Radiology
Rev
Code
0320,
036X
0320,
036X
0320,
036X
0320,
036X
0320,
036X
SI
Ind
T
T
T
T
T
2011
Action Code
2012
Code Description
Peritoneocentesis, abdominal paracentesis, or
DEL 49080
peritoneal lavage (diagnostic or therapeutic); initial
Peritoneocentesis, abdominal paracentesis, or
peritoneal lavage (diagnostic or therapeutic);
DEL 49081
subsequent
Abdominal paracentesis (diagnostic or therapeutic;
NEW
49082 without imaging guidance
Abdominal paracentesis (diagnostic or therapeutic;
NEW
49083 with imaging guidance
NEW
Peritoneal lavage, including imaging guidance,
49084 when performed
Remember to “unpanel” or “unexplode” routines which explode the ultrasound,
CT guidance or fluoroscopy (e.g. CPT 76942 or 77012)
103
Interventional Radiology
Rev
Code
036X,
0402,
032X
SI
Ind
T
2011
Action Code
2012
Code Description
Cons
Sed
47000 Biopsy of liver, needle; percutaneous
Continue to report radiology “guidance” code, e.g. ultrasound,
Fluoroscopy or CT
Code has been added to Appendix G, includes moderate/conscious
sedation
104
Interventional Radiology
Rev
SI
2011 2012
Code Ind Action Code Code Description
0361,
0320,
Destruction by neurolytic agent, paravertebral facet
0350
T DEL
64622
joint nerve; lumbar or sacral, single level
0361,
0320,
0350
T
NEW
Destruction by neurolytic agent, paravertebral facet
joint nerve(s), with imaging guidance (fluoroscopy or
64635 CT); lumbar or sacral, single facet joint
If fluoroscopic guidance is not utilized, see CPT 64999
105
Interventional Radiology
Rev
Code
SI
Ind
2011
Action Code
0361,
0320,
0350
T
DEL
0361,
0320,
0350
T
NEW
2012
Code Description
Destruction by neurolytic agent, paravertebral facet
joint nerve; lumbar or sacral, each additional level
(List separately in addition to code for primary
64623
procedure)
Destruction by neurolytic agent, paravertebral facet
joint nerve(s), with imaging guidance (fluoroscopy or
CT); lumbar or sacral, each additional facet joint
(List separately in addition to code for primary
64636 procedure)
If fluoroscopic guidance is not utilized, see CPT 64999
106
Interventional Radiology
Rev
Code
0361,
0320,
0350
0361,
0320,
0350
SI
Ind
2011
Action Code
T
DEL
T
NEW
2012
Code Description
Destruction by neurolytic agent, paravertebral facet
64626
joint nerve; cervical or thoracic, single level
Destruction by neurolytic agent, paravertebral facet
joint nerve(s), with imaging guidance (fluoroscopy or
64633 CT); cervical or thoracic, single facet joint
If fluoroscopic guidance is not utilized, see CPT 64999
107
Interventional Radiology
Rev
Code
SI
Ind
0361,
0320,
0350
T
0361,
0320,
0350
T
2011
Action Code
2012
Code Description
Destruction by neurolytic agent, paravertebral facet
joint nerve; cervical or thoracic, each additional level
(List separately in addition to code for primary
DEL
64627
procedure)
Destruction by neurolytic agent, paravertebral facet
joint nerve(s), with imaging guidance (fluoroscopy or
CT); cervical or thoracic, each additional facet joint
(List separately in addition to code for primary
NEW
64634 procedure)
If fluoroscopic guidance is not utilized, see CPT 64999
108
Surgical Procedures - Guidance
Rev
Code
SI
Ind
2011
Action Code
032X,
035X,
036X
T
NEW
032X,
035X,
036X
T
NEW
2012
Code Description
Percutaneous laminotomy/laminectomy
(intralaminar approach) for decompression of neural
elements, (with or without ligamentous resection,
discectomy, facetectomy and/or foraminotomy) any
method under indirect image guidance (eg,
fluoroscopic, CT), with or without the use of an
endoscope, single or multiple levels, unilateral or
0274T bilateral; cervical or thoracic
Percutaneous laminotomy/laminectomy
(intralaminar approach) for decompression of neural
elements, (with or without ligamentous resection,
discectomy, facetectomy and/or foraminotomy) any
method under indirect image guidance (eg,
fluoroscopic, CT), with or without the use of an
endoscope, single or multiple levels, unilateral or
0275T bilateral; lumbar
109
Surgical Procedures - Guidance
Rev
Code
SI
Ind
0920,
0929
S
0920,
0929
S
ADD
2012
Code Description
Percutanous or open implantation of
neurostimulator electrode array(s), subcutaneous
(peripheral subcutaneous field stimulation),
including imaging guidance, when performed,
cervical, thoracic or lumbar; for trial, including
0282T removal at the conclusion of trial period
ADD
Percutanous or open implantation of
neurostimulator electrode array(s), subcutaneous
(peripheral subcutaneous field stimulation),
including imaging guidance, when performed,
cervical, thoracic or lumbar; permanent, with
0283T implantation of a pulse generator
Action
2011
Code
110
Diagnostic Radiology
Rev
Code
0320
0320
Rev
0320
SI
Ind
X
X
SI
N
2011 2012
Action Code Code Description
DESC 70355
Orthopantogram
DESC
70355 Orthopantogram (eg, panoramic x-ray);
Action 2011 2012 Description
DEL
Insertion pacemaker, fluoroscopy and radiography,
71090 radiological supervision and interpretation
New parenthetical instructions in 2012 narrative specific for fluoroscopic
guidance for lead insertion, replacement or revisions
111
Diagnostic Radiology
Rev
Code
SI
Ind
0320
X
0320
Rev
X
SI
0320
X
0320
X
2011
Action Code
2012
Code Description
Radiologic examination, spine, lumbosacral;
DESC 72114
complete, including bending views
Radiologic examination, spine, lumbosacral;
complete, including bending views, minimum of 6
DESC
72114 views
Action 2011 2012 Description
Radiologic examination, spine, lumbosacral,
DESC 72120
bending views only, minimum of 4 views
Radiologic examination, spine, lumbosacral,
DESC
72120 bending views only, 2 of 3 views
112
Diagnostic Radiology
Rev
Code
SI
Ind
035X
S
035X
X
2011
Action Code
DEL
DEL
2012
Code Description
Computed tomography, bone mineral density study,
1 or more sites; appendicular skeleton (peripheral)
77079
(eg, radius, wrist, heel)
See Existing 77078, 77080-77081
77083
Radiographic absorptiometry (eg,
photodensitometry, radiogrammetry), 1 or more
sites
See Existing 77080-77082
113
Radiation Oncology
Rev
Code
SI
Ind
2011
Action Code
0333
N
NEW
0333
N
NEW
2012
Code Description
Intraoperative radiation treatment delivery, x-ray,
77424 single treatment session
Intraoperative radiation treatment delivery,
77425 electrons, single treatment session
0333
N
NEW
77469 Intraoperative radiation treatment management
114
Radiation Oncology
Rev
Code
SI
Ind
0333
S
0333
S
2011
Action Code
2012
Code Description
Special treatment procedure (eg, total body
irradiation, hemibody radiation, per oral,
DESC 77470
endocavitary or intraoperative cone irradiation)
Special treatment procedure (eg, total body
irradiation, hemibody radiation, per oral or
DESC
77470 endocavitary irradiation)
115
CT Abdomen & Pelvis Payment Adjustments 2012
HCPCS
Code
Short Descriptor
74176 Ct abd & pelvis
74177 Ct abd & pelv w/contrast
74178 Ct abd & pelv 1/> regns
SI APC
Q3 0331
Q3 0334
Q3 0334
Relative
Weight
5.7930
8.2987
8.2987
2012
Payment
Rate
$405.60
$581.04
$581.04
N
a
2011
t
Payment Payment
i
Rate
Difference
Q3
193.85
211.75
Q3
299.81
281.23
Q3
334.24
246.80
116
MRI Contrast
Rev
Code
SI
Ind
0254,
0255,
0636
N
2011
Action Code
2012
Code Description
NEW
A9585 Injection, gadobutrol, 0.1 ml
117
Computerized Tomographic Angiography (CTA)
• Continue to report using:
– 74175 Computed tomographic angiography, abdomen, with contrast
material(s), including noncontrast images, if performed, and image
postprocessing
– 72191 Computed tomographic angiography, pelvis, with contrast
material(s), including noncontrast images, if performed, and image
postprocessing
• New for 2012:
Rev
Code
0350,
0352,
0359
SI
Ind
S
2011
Action Code
2012
Code Description
NEW
Computed tomographic angiography, abdomen and
pelvis, with contrast material(s), including
noncontrast images, if performed, and image
74174 postprocessing
118
Nuclear Medicine
Rev
Code
SI
Ind
0340,
034X
Rev
S
SI
0340,
034X
S
2011
Action Code
2012
Code Description
Liver function study with hepatobiliary agents, with
DEL 78220
images
Action
2011 2012 serial
Description
Hepatobiliary ductal system imaging, including
gallbladder, with or without pharmacologic
intervention, with or without quantitative
DEL 78223
measurement of gallbladder function
0340,
034X
S
NEW
0340,
034X
S
NEW
Hepatobiliary system imaging, including gallbladder
78226 when present;
Hepatobiliary system imaging, including gallbladder
when present; with pharmacologic intervention,
including quantitative measurement(s) when
78227 performed
119
Nuclear Medicine
Rev
Code
SI
Ind
2011
Action Code
036X,
034X Q1 DESC 38792
036X,
034X Q1 DESC
2012
Code Description
Injection procedure; for identification of sentinel
node
Injection procedure;radioactive tracer for
38792 identification of sentinel node
120
Nuclear Medicine
Rev
Code
SI
Ind
2011
Action Code
0340,
034X
S
DESC 78580
0340,
034X
S
DESC
2012
Code Description
Pulmonary perfusion imaging, particulate
78580 Pulmonary perfusion imaging (eg, particulate)
121
Nuclear Medicine
SI
Rev
Code Ind
0340,
034X S
0340,
034X
0340,
034X
S
S
2012
Code Description
Pulmonary perfusion imaging, particulate, with
ventilation; single breath
78584
Pulmonary perfusion imaging, particulate, with
ventilation; rebreathing and washout, with or without
single breath
78585
2011
Action Code
DEL
DEL
DEL
78586
0340,
034X
S
DEL
78587
0340,
034X
S
DEL
78588
Pulmonary ventilation imaging, aerosol; single
projection
Pulmonary ventilation imaging, aerosol; multiple
projections (eg, anterior, posterior, lateral views)
Pulmonary perfusion imaging, particulate, with
ventilation imaging, aerosol, 1 or multiple
projections
122
Nuclear Medicine
Rev
Code
SI
Ind
2011
Action Code
2012
Code Description
0340,
034X
S
DEL
78591
0340,
034X
S
DEL
78593
0340,
034X
S
DEL
78594
Pulmonary ventilation imaging, gaseous, single
breath, single projection
Pulmonary ventilation imaging, gaseous, with
rebreathing and washout with or without single
breath; single projection
Pulmonary ventilation imaging, gaseous, with
rebreathing and washout with or without single
breath; multiple projections (eg, anterior, posterior,
lateral views)
78596
Pulmonary quantitative differential function
(ventilation/perfusion) study
0340,
034X
S
DEL
123
Nuclear Medicine
SI
Rev
Code Ind
0340,
034X S
0340,
034X
0340,
034X
S
S
2011
Action Code
2012
Code Description
NEW
78579 Pulmonary ventilation imaging (eg, aerosol or gas)
DESC
78580 Pulmonary perfusion imaging (eg, particulate)
NEW
Pulmonary ventilation (eg, aerosol or gas) and
78582 perfusion imaging
0340,
034X
S
NEW
0340,
034X
S
NEW
Quantitative differential pulmonary perfusion,
78597 including imaging when performed
Quantitative differential pulmonary perfusion and
ventilation (eg, aerosol or gas), including imaging
78598 when performed
124
Nuclear Medicine
Rev
Code
0343,
0636
0343,
0636
SI
Ind
G
G
2011
Action Code
DEL
NEW
C9406
2012
Code Description
Iodine I-123 ioflupane, diagnostic, per study dose,
up to 5 millicuries
Iodine I-123 ioflupane, diagnostic, per study dose,
A9584 up to 5 millicuries
125
Payment Changes for Radiopharmaceuticals
A9582
Iodine I-123 iobenguane
R
2012
SI
e SI
APC
l
N
G
A9583
Gadofosveset trisodium inj
N
HCPCS
Short Descriptor
Code
G
2011
Payment
2636.16
12.65
126
Laboratory, Pathology and Blood
Bank
CPT and HCPCS code changes
Molecular Diagnostics New CPT Codes
Genetic Testing New CPT Codes
Other Laboratory CPT Code Updates
In 2012, 31% of coding changes reside in the
Laboratory Chargemaster
Laboratory CPT Changes- Immunology
Rev SI
2011 2012
Code Ind Action Code Code Description
0300,
0302,
0309 A DESC 86703
Antibody; HIV-1 and HIV-2, single assay
0300,
0302,
0309 A DESC
86703 Antibody; HIV-1 and HIV-2, single result
One CPT code to report a test for both HIV I and HIV II.
129
Laboratory CPT Changes- Pathology/Histology
• In 2012, special stains have undergone descriptor
revisions
– Removal of personal identifications, e.g. Gridley
Rev
Code
SI
2011
Ind Action Code
0310,
0312
X
0310,
0312
X
2012
Code Description
Special stains; Group I for microorganisms (eg,
Gridley, acid fast, methenamine silver),
DESC 88312
including interpretation and report, each
Special stain including interpretation and
report; Group I for microorganisms (eg, acid
DESC
88312 fast, methenamine silver)
130
Laboratory CPT Changes- Pathology/Histology
Rev
Code
SI
2011
Ind Action Code
0310,
0312
X
0310,
0312
X
2012
Code Description
Special stains; Group II, all other (eg, iron,
trichrome), except immunocytochemistry and
immunoperoxidase stains, including
DESC 88313
interpretation and report, each
Special stain including interpretation and report;
Group II, all other (eg, iron, trichrome), except
stain for microorganisms, stains for enzyme
constituents or immunocytochemistry and
DESC
88313 immunohistochemistry
For determinative histochemistry to identify chemistry components, see
88313
131
Laboratory CPT Changes- Pathology/Histology
Rev
Code
0310,
0312
0310,
0312
SI
2011
Ind Action Code
X
DEL
88318
X
Exist
88313
2012
Code Description
Determinative histochemistry to identify
chemical components (eg, copper, zinc)
Special stain including interpretation and report;
Group II, all other (eg, iron, trichrome), except
stain for microorganisms, stains for enzyme
constituents or immunocytochemistry and
immunohistochemistry
132
Laboratory CPT Changes- Pathology/Histology
Rev
Code
SI
2011
Ind Action Code
0310,
0312
X
0310,
0312
X
2012
Code Description
Special stains; histochemical staining with
frozen section(s), including interpretation
and report (List separately in addition to code
DESC 88314
for primary procedure)
Special stain including interpretation and
report; histochemical stain on frozen tissue
block (List separately in addition to code for
DESC
88314 primary procedure)
133
Laboratory CPT Changes- Pathology/Histology
Rev
Code
0310,
0312
0310,
0312
SI
2011
Ind Action Code
X
X
2012
Code Description
Determinative histochemistry or cytochemistry
DESC 88319
to identify enzyme constituents, each
Special stains including interpretation and
DESC
88319 report; Group III for enzyme constituents
Deleted reference to histochemistry or cytochemistry in 2012.. Any time
performing a special stain for enzyme constituents, reportable using
CPT 88319.
134
Laboratory CPT Changes- Pathology/Histology
Rev
Code
SI
2011
Ind Action Code
0310,
0311
X
DEL
0310,
0311
X
Exist
0310,
0311
X
Exist
2012
Code Description
Cytopathology, fluids, washings or brushings,
except cervical or vaginal; smears and simple
88107
filter preparation with interpretation
Cytopathology, fluids, washings or brushings,
except cervical or vaginal; simple filter method
88106 with interpretation
Cytopathology, fluids, washings or brushings,
except cervical or vaginal; smears with
88104 interpretation
135
NEW Laboratory CPT Codes- Immunology
Rev SI
2011
Code Ind Action Code
0300,
0302,
0309 A ADD
2012
Code Description
86386 Nuclear Matrix Protein 22 (NMP22), qualitative
136
NEW Laboratory CPT Codes- Bacteriology/Microbiology
Rev
Code
0300,
0306,
0309
SI
2011
Ind Action Code
A
ADD
2012
Code Description
Infectious agent antigen detection by enzyme
immunoassay technique, qualitative or
semiquantitative, multiple-step method; HIV-1
antigen(s), with HIV-1 and HIV-2 antibodies,
87389 single result
137
Significant Laboratory Code Additions
• New Molecular Codes
– Phase I
• Infectious disease agent DNA probes, direct and amplified
– Moved from Chemistry section to the 87XXX Code Range
– Phase II
• Revisions were planned prior to 2010
– Codes were not unexpected or unannounced
– Welcome by facilities that perform molecular diagnostics
138
Molecular Pathology
• New Section between Urinalysis and Chemistry
– New Terminology
– New Definitions
• Tier I Molecular Diagnostics
• Tier II Molecular Pathology Procedures
139
140
141
Significant Laboratory Code Additions
 Molecular diagnostics
o Genomics, analysis of genes

o
Genetic testings are encompassed in
molecular diagnostics
Protein aberrations that can manifest as
disease
 Molecular pathology
o Looking for variants of enzymes, factors or
alleles responsible for impairment or
disease
142
Molecular Diagnostics and Genetic Testing
• Many techniques to determine if DNA sample has a mutation. Method
of testing, when specified in a code, becomes a key coding term
First Tier of Codes
• Common genetic tests for
uncommon genetic diseases
• CPT 812XX – 813XX codes
• Over 112 genetic tests for solid
tumors and hematological cancers
Second Tier of Codes
• Molecular Pathology
• As many as 1,000 tests are
reported using one of nine
Molecular Pathology CPT codes
• CPT 81400-81408
143
Molecular Diagnostics and Genetic Testing
• For 2012 new codes:
– Eliminate code stacking
• Explode codes
• Multiple codes that reflect each step performed when
doing genetic test or molecular diagnostic procedure
– Cystic fibrosis test panel could have 5-9 separately
reportable CPT codes
• In 2012-one CPT code to report a single genetic
assay
144
Molecular Diagnostics and Genetic Testing
• Changes in 2012 are essentially moving away from the
assignment of several nonspecific molecular codes to a
single specific code
– Less charge lines
– Fewer explode panels
• Molecular Pathology levels are similar to those in surgical
pathology levels
– Expand coding options for HLAS to include HLA-typing by
genetic testing
• Important for transplant, typing and matching
145
Molecular Diagnostics and Genetic Testing
• If performing molecular diagnostic or genetic testing code updates:
– Read preamble and parenthetical statements in Laboratory Section
of 2012 CPT book
– Become familiar with acronyms in new CPT code descriptions
• Acronyms are standardized
• Codes are alphabetized
– Develop standardized chargemaster descriptions for new codes
– Consider creating unique cost center for molecular/genetics
• Some codes may be currently in Molecular, others in Chemistry
– Review explode panels currently in use
– Review use of genetic modifiers, Appendix I
• Used primarily by independent laboratories, not by hospitals
146
Molecular Diagnostics and Genetic Testing
• If performing molecular diagnostic or genetic testing code
updates:
• Work closely with Reference Lab when assigning codes
• If performed in-house, may need to refer to test-kit
inserts or laboratory procedure manuals
– May not know if target is major or minor break point
147
Molecular Diagnostics and Genetic Testing
• Currently Medicare is reimbursing only for Warfarin test
– A pharmacogenetic test to determine how a patient
metabolizes this specific drug
• Coverage of these new codes by Medicare and payers
should not be assumed
– Medicare has met to determine the applicability of these new
codes, medical necessity and how to address them in the
laboratory fee schedule
148
Molecular Diagnostics and Genetic Testing
References:
– International Society of Genetic Geneology
• http://www.ISOGG.org
– Glossary of DNA terms
– National Cancer Institute
• http://www.CANCER.gov
– Tutorials
• Molecular diagnostics and is straightforward (found
under cancer topics)
149
Molecular Diagnostics and Genetic Testing
• Tier I – Molecular Pathology
– Codes 81200-81350
• Gene-specific and genomic procedures
• Tier 2 – Molecular Pathology
– Codes 81400-81408
• Medically useful procedures that are generally
performed in lower volumes than Tier I procedures
• If the analyte tested is not listed under one of the Tier 2
codes or is not represented by a Tier code, use the
appropriate methodology codes in the 83890-83914 and
88384-88386 series
150
Molecular Diagnostics and Genetic Testing-Tier 1
Rev
Code
0300,
0301,
0309
0300,
0301,
0309
SI
2011
Ind Action Code
B
ADD
B
ADD
2012
Code Description
ASPA (aspartoacylase) (eg, Canavan disease)
gene analysis, common variants (eg, E285A,
81200 Y231X)
BCKDHB (branched-chain keto acid
dehydrogenase E1, beta polypeptide) (eg, Maple
syrup urine disease) gene analysis, common
81205 variants (eg, R183P, G278S, E422X)
151
Molecular Diagnostics and Genetic Testing-Tier 1
Rev
Code
0300,
0301,
0309
0300,
0301,
0309
0300,
0301,
0309
SI
2011
Ind Action Code
B
ADD
B
ADD
B
ADD
2012
Code Description
BCR/ABL1 (t(9;22)) (eg, chronic myelogenous
leukemia) translocation analysis; major
81206 breakpoint, qualitative or quantitative
BCR/ABL1 (t(9;22)) (eg, chronic myelogenous
leukemia) translocation analysis; minor
81207 breakpoint, qualitative or quantitative
BCR/ABL1 (t(9;22)) (eg, chronic myelogenous
leukemia) translocation analysis; other
81208 breakpoint, qualitative or quantitative
152
Molecular Diagnostics and Genetic Testing-Tier 1
Rev
Code
0300,
0301,
0309
0300,
0301,
0309
SI
2011
Ind Action Code
B
ADD
B
ADD
2012
Code Description
BLM (Bloom syndrome, RecQ helicase-like) (eg,
Bloom syndrome) gene analysis, 2281del6ins7
81209 variant
BRAF (v-raf murine sarcoma viral oncogene
homolog B1) (eg, colon cancer), gene analysis,
81210 V600E variant
153
Molecular Diagnostics and Genetic Testing-Tier 1
Rev
Code
0300,
0301,
0309
0300,
0301,
0309
0300,
0301,
0309
SI
2011
Ind Action Code
B
ADD
B
ADD
B
ADD
2012
Code Description
BRCA1, BRCA2 (breast cancer 1 and 2) (eg,
hereditary breast and ovarian cancer) gene
analysis; full sequence analysis and common
duplication/deletion variants in BRCA1 (ie, exon
13 del 3.835kb, exon 13 dup 6kb, exon 14-20 del
81211 26kb, exon 22 del 510bp, exon 8-9 del 7.1kb)
BRCA1, BRCA2 (breast cancer 1 and 2) (eg,
hereditary breast and ovarian cancer) gene
81212 analysis; 185delAG, 5385insC, 674delT variants
BRCA1, BRCA2 (breast cancer 1 and 2) (eg,
hereditary breast and ovarian cancer) gene
analysis; uncommon duplication/deletion
81213 variants
154
Molecular Diagnostics and Genetic Testing-Tier 1
Rev
Code
0300,
0301,
0309
0300,
0301,
0309
SI
2011
Ind Action Code
B
ADD
B
ADD
2012
Code Description
BRCA1 (breast cancer 1) (eg, hereditary breast
and ovarian cancer) gene analysis; full sequence
analysis and common duplication/deletion
variants (ie, exon 13 del 3.835kb, exon 13 dup
6kb, exon 14-20 del 26kb, exon 22 del 510kb,
81214 exon 8-9 del 7.1kb)
BRCA1 (breast cancer 1) (eg, hereditary breast
and ovarian cancer) gene analysis; known
81215 familial variant
155
Molecular Diagnostics and Genetic Testing-Tier 1
Rev
Code
0300,
0301,
0309
0300,
0301,
0309
SI
2011
Ind Action Code
B
ADD
B
ADD
2012
Code Description
BRCA2 (breast cancer 2) (eg, hereditary breast
and ovarian cancer) gene analysis; full sequence
81216 analysis
BRCA2 (breast cancer 2) (eg, hereditary breast
and ovarian cancer) gene analysis; known
81217 familial variant
156
Molecular Diagnostics and Genetic Testing-Tier 1
Rev
Code
0300,
0301,
0309
0300,
0301,
0309
0300,
0301,
0309
0300,
0301,
0309
0300,
0301,
0309
SI
Ind Action
B
ADD
B
ADD
B
ADD
B
ADD
B
ADD
2011
Code
2012
Code Description
CFTR (cystic fibrosis transmembrane
conductance regulator) (eg, cystic fibrosis) gene
analysis; common variants (eg, ACMG/ACOG
81220 guidelines)
CFTR (cystic fibrosis transmembrane
conductance regulator) (eg, cystic fibrosis) gene
81221 analysis; known familial variants
CFTR (cystic fibrosis transmembrane
conductance regulator) (eg, cystic fibrosis) gene
81222 analysis; duplication/deletion variants
CFTR (cystic fibrosis transmembrane
conductance regulator) (eg, cystic fibrosis) gene
81223 analysis; full gene sequence
CFTR (cystic fibrosis transmembrane
conductance regulator) (eg, cystic fibrosis) gene
analysis; intron 8 poly-T analysis (eg, male
81224 infertility)
157
Molecular Diagnostics and Genetic Testing-Tier 1
Rev
Code
0300,
0301,
0309
B
ADD
0300,
0301,
0309
B
ADD
2012
Code Description
CYP2C19 (cytochrome P450, family 2,
subfamily C, polypeptide 19) (eg, drug
metabolism), gene analysis, common variants
81225 (eg, *2, *3, *4, *8, *17)
CYP2D6 (cytochrome P450, family 2, subfamily
D, polypeptide 6) (eg, drug metabolism), gene
analysis, common variants (eg, *2, *3, *4, *5, *6,
*9, *10, *17, *19, *29, *35, *41, *1XN, *2XN,
81226 *4XN)
ADD
CYP2C9 (cytochrome P450, family 2, subfamily
C, polypeptide 9) (eg, drug metabolism), gene
81227 analysis, common variants (eg, *2, *3, *5, *6)
0300,
0301,
0309
SI
2011
Ind Action Code
B
Drug Metabolism testing
158
Molecular Diagnostics and Genetic Testing-Tier 1
Rev
Code
SI
2011
Ind Action Code
0300,
0301,
0309
B
ADD
0300,
0301,
0309
B
ADD
2012
Code Description
Cytogenomic constitutional (genome-wide)
microarray analysis; interrogation of genomic
regions for copy number variants (eg, Bacterial
Artificial Chromosome [BAC] or oligo-based
comparative genomic hybridization [CGH]
81228 microarray analysis)
Cytogenomic constitutional (genome-wide)
microarray analysis; interrogation of genomic
regions for copy number and single nucleotide
polymorphism (SNP) variants for chromosomal
81229 abnormalities
159
Molecular Diagnostics and Genetic Testing-Tier 1
Rev
Code
0300,
0301,
0309
0300,
0301,
0309
0300,
0301,
0309
SI
2011
Ind Action Code
B
ADD
B
ADD
B
ADD
2012
Code Description
F2 (prothrombin, coagulation factor II) (eg,
hereditary hypercoagulability) gene analysis,
81240 20210G>A variant
F5 (coagulation Factor V) (eg, hereditary
81241 hypercoagulability) gene analysis, Leiden variant
FANCC (Fanconi anemia, complementation
group C) (eg, Fanconi anemia, type C) gene
81242 analysis, common variant (eg, IVS4+4A>T)
160
Molecular Diagnostics and Genetic Testing-Tier 1
Rev
Code
SI
2011
Ind Action Code
0300,
0301,
0309
B
ADD
0300,
0301,
0309
B
ADD
0300,
0301,
0309
B
ADD
2012
Code Description
FMR1 (Fragile X mental retardation 1) (eg, fragile
X mental retardation) gene analysis; evaluation
81243 to detect abnormal (eg, expanded) alleles
FMR1 (Fragile X mental retardation 1) (eg, fragile
X mental retardation) gene analysis;
characterization of alleles (eg, expanded size
81244 and methylation status)
FLT3 (fms-related tyrosine kinase 3) (eg, acute
myeloid leukemia), gene analysis, internal
tandem duplication (ITD) variants (ie, exons 14,
81245 15)
161
Molecular Diagnostics and Genetic Testing-Tier 1
Rev
Code
0300,
0301,
0309
0300,
0301,
0309
0300,
0301,
0309
SI
2011
Ind Action Code
B
ADD
B
ADD
B
ADD
2012
Code Description
G6PC (glucose-6-phosphatase, catalytic
subunit) (eg, Glycogen storage disease, Type
1a, von Gierke disease) gene analysis, common
81250 variants (eg, R83C, Q347X)
GBA (glucosidase, beta acid) (eg, Gaucher
disease) gene analysis, common variants (eg,
81251 N370S, B4GG, L444P, IVS2+1G>A)
HEXA (hexosaminidase A [alpha polypeptide])
(eg, Tay-Sachs disease) gene analysis,
common variants (eg, 1278insTATC, 1421+G>C,
81255 G269S)
162
Molecular Diagnostics and Genetic Testing-Tier 1
Rev
Code
0300,
0301,
0309
SI
2011
Ind Action Code
B
ADD
0300,
0301,
0309
B
ADD
0300,
0301,
0309
B
ADD
2012
Code Description
HFE (hemochromatosis) (eg, hereditary
hemochromatosis) gene analysis, common
81256 variants (eg, C282Y, H63D)
HBA1/HBA2 (alpha globin 1 and alpha globin 2)
(eg, alpha thalassema, Hb Bart hydrops fetalis
syndrome, HbH disease), gene analysis, for
common deletions or variant (eg, Southeast
Asian, Thai, Filipino, Mediterranean, alpha3.7,
81257 alpha4.2, alpha20.5, and Constant Spring)
IKBKAP (inhibitor of kappa light polypeptide
gene enhancer in B-cells, kinase complexassociated protein) (eg, familial dysautonomia)
gene analysis, common variants (eg,
81260 2507+6T>C, R696P)
163
Molecular Diagnostics and Genetic Testing-Tier 1
Rev
Code
0300,
0301,
0309
0300,
0301,
0309
0300,
0301,
0309
0300,
0301,
0309
SI
2011
Ind Action Code
B
ADD
B
ADD
B
ADD
B
ADD
2012
Code Description
IGH@ (Immunoglobulin heavy chain locus) (eg,
leukemias and lymphomas, B-cell), gene
rearrangement analysis to detect abnormal
clonal population(s); amplified methodology (eg,
81261 polymerase chain reaction)
IGH@ (Immunoglobulin heavy chain locus) (eg,
leukemias and lymphomas, B-cell), gene
rearrangement analysis to detect abnormal
clonal population(s); direct probe methodology
81262 (eg, Southern blot)
IGH@ (Immunoglobulin heavy chain locus) (eg,
leukemia and lymphoma, B-cell), variable region
81263 somatic mutation analysis
IGK@ (Immunoglobulin kappa light chain locus)
(eg, leukemia and lymphoma, B-cell) gene
rearrangement analysis, evaluation to detect
81264 abnormal clonal population(s)
164
Molecular Diagnostics and Genetic Testing-Tier 1
Rev
Code
SI
2011
Ind Action Code
0300,
0301,
0309
B
ADD
0300,
0301,
0309
B
ADD
2012
Code Description
Comparative analysis using Short Tandem
Repeat (STR) markers; patient and comparative
specimen (eg, pre-transplant recipient and donor
germline testing, post-transplant nonhematopoietic recipient germline (eg, buccal
swab orother germline tissue sample) and donor
testing, twin zygosity testing, or maternal cll
81265 contamination of fetal cells)
Comparative analysis using Short Tandem
Repeat (STR) markers; each additional
specimen (eg, additional cord blood donor,
additional fetal samples from different cultures,
or additional zygosity in multiple birth
pregnancies) (List separately in addition to code
81266 for primary procedure)
165
Molecular Diagnostics and Genetic Testing-Tier 1
Rev
Code
SI
2011
Ind Action Code
0300,
0301,
0309
B
ADD
0300,
0301,
0309
B
ADD
2012
Code Description
Chimerism (engraftment) analysis, post
transplantation specimen (eg, hematopoietic
stem cell), includes comparison to previously
performed baseline analysis; without cell
81267 selection
Chimerism (engraftment) analysis, post
transplantation specimen (eg, hematopoietic
stem cell), includes comparison to previously
performed baseline analysis; with cell selection
81268 (eg, CD3, CD33), each cell type
Comparing a specimen today with a previous specimen to see if there
are two types of DNA---used to check if stem cell transplant has taken
166
Molecular Diagnostics and Genetic Testing-Tier 1
Rev
Code
0300,
0301,
0309
0300,
0301,
0309
SI
2011
Ind Action Code
B
ADD
B
ADD
2012
Code Description
JAK2 (Janus kinase 2) (eg, myeloproliferative
disorder) gene analysis, p.Val617Phe (V617F)
81270 variant
KRAS (v-Ki-ras2 Kirsten rat sarcoma viral
oncogene) (eg, carcinoma) gene analysis,
81275 variants in codons 12 and 13
167
Molecular Diagnostics and Genetic Testing-Tier 1
Rev
Code
0300,
0301,
0309
B
ADD
0300,
0301,
0309
B
ADD
2012
Code Description
Long QT syndrome gene analyses (eg, KCNQ1,
KCNH2, SCN5A, KCNE1, KCNE2, KCNJ2,
CACNA1C, CAV3, SCN4B, AKAP, SNTA1, and
81280 ANK2); full sequence analysis
Long QT syndrome gene analyses (eg, KCNQ1,
KCNH2, SCN5A, KCNE1, KCNE2, KCNJ2,
CACNA1C, CAV3, SCN4B, AKAP, SNTA1, and
81281 ANK2); known familial sequence variant
ADD
Long QT syndrome gene analyses (eg, KCNQ1,
KCNH2, SCN5A, KCNE1, KCNE2, KCNJ2,
CACNA1C, CAV3, SCN4B, AKAP, SNTA1, and
81282 ANK2); duplication/deletion variants
0300,
0301,
0309
SI
2011
Ind Action Code
B
168
Molecular Diagnostics and Genetic Testing-Tier 1
Rev
Code
0300,
0301,
0309
0300,
0301,
0309
SI
2011
Ind Action Code
B
ADD
B
ADD
2012
Code Description
MCOLN1 (mucolipin 1) (eg, Mucolipidosis, type
(V) gene analysis, common variants (eg, IVS381290 2A>G, del6.4kb)
MTHFR (5, 10-methylenetetrahydrofalate
reductase) (eg, hereditary hypercoagulability)
gene analysis, common variants (eg, 677T,
81291 1298C)
169
Molecular Diagnostics and Genetic Testing-Tier 1
Rev
Code
SI
2011
Ind Action Code
0300,
0301,
0309
B
ADD
0300,
0301,
0309
B
ADD
0300,
0301,
0309
B
ADD
2012
Code Description
MLH1 (mutL homolog 1, colon cancer,
nonpolyposis type 2) (eg, hereditary nonpolyposis colorectal cancer, Lynch syndrome)
81292 gene analysis; full sequence analysis
MLH1 (mutL homolog 1, colon cancer,
nonpolyposis type 2) (eg, hereditary nonpolyposis colorectal cancer, Lynch syndrome)
81293 gene analysis; known familial variants
MLH1 (mutL homolog 1, colon cancer,
nonpolyposis type 2) (eg, hereditary nonpolyposis colorectal cancer, Lynch syndrome)
81294 gene analysis; duplication/deletion variants
170
Molecular Diagnostics and Genetic Testing-Tier 1
Rev
Code
2011
SI
Ind Action Code
0300,
0301,
0309
B
ADD
0300,
0301,
0309
B
ADD
0300,
0301,
0309
B
ADD
2012
Code Description
MSH2 (mutS homolog 2, colon cancer,
nonpolyposis type 1) (eg, hereditary nonpolyposis colorectal cancer, Lynch syndrome)
81295 gene analysis; full sequence analysis
MSH2 (mutS homolog 2, colon cancer,
nonpolyposis type 1) (eg, hereditary nonpolyposis colorectal cancer, Lynch syndrome)
81296 gene analysis; known familial variants
MSH2 (mutS homolog 2, colon cancer,
nonpolyposis type 1) (eg, hereditary nonpolyposis colorectal cancer, Lynch syndrome)
81297 gene analysis; duplication/deletion variants
171
Molecular Diagnostics and Genetic Testing-Tier 1
Rev
Code
0300,
0301,
0309
0300,
0301,
0309
0300,
0301,
0309
SI
2011
Ind Action Code
B
ADD
B
ADD
B
ADD
2012
Code Description
MSH6 (mutS homolog 6 [E. coli]) (eg, hereditary
non-polyposis colorectal cancer, Lynch
81298 syndrome) gene analysis; full sequence analysis
MSH6 (mutS homolog 6 [E. coli]) (eg, hereditary
non-polyposis colorectal cancer, Lynch
81299 syndrome) gene analysis; known familial variants
MSH6 (mutS homolog 6 [E. coli]) (eg, hereditary
non-polyposis colorectal cancer, Lynch
syndrome) gene analysis; duplication/deletion
81300 variants
172
Molecular Diagnostics and Genetic Testing-Tier 1
Rev
Code
0300,
0301,
0309
SI
2011
Ind Action Code
B
ADD
2012
Code Description
Microsatellite instabiilty analysis (eg, hereditary
non-polyposis colorectal cancer, Lynch
syndrome) or markers for mismatch repair
deficiency (eg, BAT25, BAT26), includes
comparison of neoplastic and normal tissue, if
81301 performed
173
Molecular Diagnostics and Genetic Testing-Tier 1
Rev
Code
0300,
0301,
0309
0300,
0301,
0309
0300,
0301,
0309
SI
2011
Ind Action Code
B
ADD
B
ADD
B
ADD
2012
Code Description
MECP2 (methyl CpG binding protein 2) (eg, Rett
81302 syndrome) gene analysis; full sequence analysis
MECP2 (methyl CpG binding protein 2) (eg, Rett
81303 syndrome) gene analysis; known familial variant
MECP2 (methyl CpG binding protein 2) (eg, Rett
syndrome) gene analysis; duplication/deletion
81304 variants
174
Molecular Diagnostics and Genetic Testing-Tier 1
Rev
Code
0300,
0301,
0309
SI
2011
Ind Action Code
B
ADD
2012
Code Description
NPM1 (nucleophosmin) (eg, acute myeloid
81310 leukemia) gene analysis, exon 12 variants
175
Molecular Diagnostics and Genetic Testing-Tier 1
Rev
Code
SI
2011
Ind Action Code
0300,
0301,
0309
B
ADD
0300,
0301,
0309
B
ADD
2012
Code Description
PML/RARalpha, (t(15; 17)), (promyelocytic
leukemia/retinoic acid receptor alpha) (eg,
promyelocytic leukemia) translocation analysis;
common breakpoints (eg, intron 3 and intron 6),
81315 qualitative or quanitative
PML/RARalpha, (t(15; 17)), (promyelocytic
leukemia/retinoic acid receptor alpha) (eg,
promyelocytic leukemia) translocation analysis;
single breakpoint (eg, intron 3, intron 6 or exon
81316 6), qualitative or quantitative
176
Molecular Diagnostics and Genetic Testing-Tier 1
Rev
Code
SI
2011
Ind Action Code
0300,
0301,
0309
B
ADD
0300,
0301,
0309
B
ADD
0300,
0301,
0309
B
ADD
2012
Code Description
PMS2 (postmeiotic segregation increased 2 [?S.
cerevisiae]) (eg, hereditary non-polyposis
colorectal cancer, Lynch syndrome) gene
81317 analysis; full sequence analysis
PMS2 (postmeiotic segregation increased 2 [?S.
cerevisiae]) (eg, hereditary non-polyposis
colorectal cancer, Lynch syndrome) gene
81318 analysis; known familial variants
PMS2 (postmeiotic segregation increased 2 [?S.
cerevisiae]) (eg, hereditary non-polyposis
colorectal cancer, Lynch syndrome) gene
81319 analysis; duplication/deletion variants
177
Molecular Diagnostics and Genetic Testing-Tier 1
Rev
Code
0300,
0301,
0309
SI
2011
Ind Action Code
B
ADD
0300,
0301,
0309
B
ADD
0300,
0301,
0309
B
ADD
2012
Code Description
SMPD1 (sphingomyel phosphodiesterase 1, acid
lysosomal) (eg, Niemann-Pick disease, Type A)
gene analysis, common variants (eg, R496L,
81330 L302P, fsP330)
SNRPN/UBE3A (small nuclear ribonucleoprotein
polypeptide N and ubiquitin protein ligase E3A)
(eg, Prader-Will syndrome and/or Angelman
81331 syndrome), methylation analysis
SERPINA1 (serpin peptidase inhibitor, clade A,
alpha-1 antiproteinase, antitrypsin, member 1)
(eg, alpha-1-antitrypsin deficiency), gene
81332 analysis, common variants (eg, *S and *Z)
178
Molecular Diagnostics and Genetic Testing-Tier 1
Rev
Code
SI
2011
Ind Action Code
0300,
0301,
0309
B
ADD
0300,
0301,
0309
B
ADD
2012
Code Description
TRB@ (T cell antigen receptor, beta) (eg,
leukemia and lymphoma), gene rearrangement
analysis to detect abnormal clonal population(s);
using amplification methodology (eg, polymerase
81340 chain reaction)
TRB@ (T cell antigen receptor, beta) (eg,
leukemia and lymphoma), gene rearrangement
analysis to detect abnormal clonal population(s);
using direct probe methodology (eg, Southern
81341 blot)
179
Molecular Diagnostics and Genetic Testing-Tier 1
Rev
Code
0300,
0301,
0309
B
ADD
0300,
0301,
0309
B
ADD
2012
Code Description
TRG@ (T cell antigen receptor, gamma) (eg,
leukemia and lymphoma), gene rearrangement
analysis, evaluation to detect abnormla clonal
81342 population(s)
UGT1A1 (UDP glucuronosyltransferase 1 family,
polypeptide A1) (eg, irinotecan metabolism),
gene analysis, common variants (eg, *28, *36,
81350 *37)
ADD
VKORC1 (vitamin K epoxide reductase complex,
subunit 1) (eg, warfarin metabolism), gene
81355 analysis, common variants (eg, -16397/3673)
0300,
0301,
0309
SI
2011
Ind Action Code
B
180
Molecular Diagnostics and Genetic Testing-Tier 1
• Human Leukocyte Antigen – HLA Testing
• Codes 81370-81383
– Assess recipient and potential donor compatibility for
solid organ or hematopoetic stem cell transplantation
• HLA alleles and allele groups associated with specific
diseases and response to drug therapy
– Each HLA gene typically has multiple variant alleles or
allele groups that can be identified for grouping
181
Molecular Diagnostics and Genetic Testing-Tier 1
Rev
Code
0300,
0301,
0309
0300,
0301,
0309
0300,
0301,
0309
SI
2011
Ind Action Code
B
ADD
B
ADD
2012
Code Description
HLA Class I and II typing, low resolution (eg,
antigen equivalents); HLA-A, -B, -C, -DRB1/3/4/5
81370 and -DQB1
HLA Class I and II typing, low resolution (eg,
antigen equivalents); HLA-A, -B and -DRB1/3/4/5
81371 (eg, verification typing)
ADD
HLA Class I typing, low resolution (eg, antigen
81372 equivalents); complete (ie HLA-A, -B and -C)
B
182
Molecular Diagnostics and Genetic Testing-Tier 1
Rev
Code
0300,
0301,
0309
0300,
0301,
0309
SI
2011
Ind Action Code
B
ADD
B
ADD
2012
Code Description
HLA Class I typing, low resolution (eg, antigen
equivalents); one locus (eg, HLA-A, -B, or -C),
81373 each
HLA Class I typing, low resolution (eg, antigen
equivalents); one antigen equivalent (eg, B*27),
81374 each
183
Molecular Diagnostics and Genetic Testing-Tier 1
Rev
Code
0300,
0301,
0309
0300,
0301,
0309
0300,
0301,
0309
SI
2011
Ind Action Code
2012
Code Description
B
ADD
B
ADD
HLA Class II typing, low resolution (eg, antigen
81375 equivalents); HLA-DRB1/3/4/5 and -DQB1
HLA Class II typing, low resolution (eg, antigen
equivalents); one locus (eg, HLA-DRB1/3/4/5, 81376 DQB1, -DQA1, -DPB1, or -DPA1), each
ADD
HLA Class II typing, low resolution (eg, antigen
81377 equivalents); one antigen equivalent, each
B
184
Molecular Diagnostics and Genetic Testing-Tier 1
Rev
Code
0300,
0301,
0309
0300,
0301,
0309
0300,
0301,
0309
0300,
0301,
0309
SI
2011
Ind Action Code
B
ADD
B
ADD
B
ADD
B
ADD
2012
Code Description
HLA Class I and II typing, high resolution (ie,
alleles or allele groups), HLA-A, -B, -C, and 81378 DRB1
HLA Class I typing, high resolution (ie, alleles or
81379 allele groups); complete (ie, HLA-A, -B and -C);
HLA Class I typing, high resolution (ie, alleles or
allele groups); one locus (eg, HLA-A, -B, or -C),
81380 each
HLA Class I typing, high resolution (ie, alleles or
allele groups); one allele or allele group (eg,
81381 B*57:01P), each
185
Molecular Diagnostics and Genetic Testing-Tier 1
Rev
Code
0300,
0301,
0309
0300,
0301,
0309
SI
2011
Ind Action Code
B
B
ADD
ADD
2012
Code Description
HLA Class II typing, high resolution (ie, alleles or
allele groups); one locus (eg, HLA-DRB1, DRB3, -DRB4, -DRB5, -DQB1, -DQA1, -DPB1,
81382 or -DPA1), each
HLA Class II typing, high resolution (ie, alleles or
allele groups); one allele or allele group (eg, HLA81383 DQB1 *06:02P), each
186
Molecular Pathology-Tier 2
Molecular Pathology
• Looking for variants of enzymes, alleles that are
responsible for impairment or disease
– Codes assigned based on key indicators in descriptors by
number of SNPS, variants or exons
• As SNPS go up, variants go up and the analysis performed
becomes more complex
– First level describes an analysis of a single SNP using a fairly
straightforward technique
– Level 9 describes an analysis of more than 50 exons in a
single gene that encompasses whole genome sequency test
188
Molecular Pathology-Tier 2
Rev
Code
SI
2011
Ind Action Code
0300,
0301,
0309
B
ADD
0300,
0301,
0309
B
ADD
2012
Code Description
Molecular pathology procedure, Level 1 (eg,
identification of single germline variant [eg, SNP]
by techniques such as restriction enzyme
81400 digestion or melt curve analysis)
Molecular pathology procedure, Level 2 (eg, 2-10
SNPs, 1 methylated variant, or 1 somatic variant
[typically using nonsequencing target variant
analysis], or detection of a dynamic mutation
81401 disorder/triplet repeat)
189
Molecular Pathology -Tier 2
Rev
Code
SI
2011
Ind Action Code
0300,
0301,
0309
B
ADD
0300,
0301,
0309
B
ADD
2012
Code Description
Molecular pathology procedure, Level 3 (eg, >10
SNPs, 2-10 methylated variants, or 2-10 somatic
variants [typically using non-sequencing target
variant analysis], immunoglobulin and T-cell
receptor gene rearrangements,
81402 duplication/deletion variants 1 exon)
Molecular pathology procedure, Level 4 (eg,
analysis of single exon by DNA sequence
analysis, analysis of >10 amplicons using
multiplex PCR in 2 or more independent
reactions, mutation scanning or
81403 duplication/deletion variants of 2-5 exons)
190
Molecular Pathology-Tier 2
Rev
Code
SI
2011
Ind Action Code
0300,
0301,
0309
B
ADD
0300,
0301,
0309
B
ADD
2012
Code Description
Molecular pathology procedure, Level 5 (eg,
analysis of 2-5 exons by DNA sequence
analysis, mutation scanning or
duplication/deletion variants of 6-10 exons, or
characterization of a dynamic mutation
81404 disorder/triplet repeat by Southern blot analysis)
Molecular pathology procedure, Level 6 (eg,
analysis of 6-10 exons by DNA sequence
analysis, mutation scanning or
81405 duplication/deletion variants of 11-25 exons)
191
Molecular Pathology-Tier 2
Rev
Code
SI
2011
Ind Action Code
0300,
0301,
0309
B
ADD
0300,
0301,
0309
B
ADD
2012
Code Description
Molecular pathology procedure, Level 7 (eg,
analysis of 11-25 exons by DNA sequence
analysis, mutation scanning or
duplication/deletion variants of 26-50 exons,
81406 cytogenomic array analysis for neoplasia)
Molecular pathology procedure, Level 8 (eg,
analysis of 26-50 exons by DNA sequence
analysis, mutation scanning or
duplication/deletion variants of > 50 exons,
sequence analysis of multiple genes on one
81407 platform)
192
Molecular Pathology-Tier 2
Rev
Code
0300,
0301,
0309
SI
2011
Ind Action Code
B
ADD
2012
Code Description
Molecular pathology procedure, Level 9 (eg,
analysis of > 50 exons in a single gene by DNA
81408 sequence analysis)
193
Other Laboratory Testing
Rev
Code
SI
2011
Ind Action Code
0300,
0309,
X
ADD
0300,
0309,
X
ADD
2012
Code Description
Cell enumeration using immunologic selection
and identification in fluid specimen (eg,
0279T circulating tumor cells in blood);
Cell enumeration using immunologic selection
and identification in fluid specimen (eg,
circulating tumor cells in blood); interpretation
0280T and report
For cell enumeration using immunologic selection and
identification in fluid specimen (eg, circulating tumor cells in blood)
194
Anesthesia Services
No CPT and HCPCS code changes
Infusion Services
CPT and HCPCS code changes
Infusion Services
For both facility and physician reporting:
• Initial
– Only one initial code should be reported unless the protocol or
patient’s condition requires two separate IV sites be utilized
• Reportable with modifier -59
• Sequential
– An infusion or IV push of a new substance or drug following a primary or
initial service
• Concurrent
– Infusion of a new substance or drug infused at the same time as another
substance or drug
• Hydration may not be reported concurrently with any other service
197
Infusion Services
• When reporting codes for which infusion time is a factor
– Use the actual time over which the infusion is administered
– Injections given before and after midnight may be both
reported as an initial since they were not continuous……
– For continuous services that last beyond midnight, use the
date in which the service began and report the total units of
time provided continuously.
– A “keep open” infusion of any time is not separately reported
198
Infusion Services
• Some chemotherapeutic agents and other therapeutic agents require
pre- and/or post-hydration to be given in order to avoid specific
toxicities
– Minimum 31 minutes duration of hydration required
– Not used for the purpose of intravenous fluid is to “keep open” an IV
line prior to or subsequent to a therapeutic infusion or as a freeflowing IV during chemotherapy or other therapeutic infusion
199
Infusion Therapy Services
Rev
SI
Code Ind Action
0260,
Var
S DESC
0260,
Var
S DESC
2011
Code
2012
Code Description
Intravenous infusion, for therapy, prophylaxis, or
diagnosis (specify substance or drug); additional
sequential infusion, up to 1 hour (List separately in
96367
addition to code for primary procedure)
Intravenous infusion, for therapy, prophylaxis, or
diagnosis (specify substance or drug); additional
sequential infusion of a new drug/substance, up to
1 hour (List separately in addition to code for
96367 primary procedure)
200
Payment Comparison October 2011 to 2012
HCPCS
Code
96366
96371
96372
90471
G0010
Short Descriptor
Ther/proph/diag iv inf addon
Sc ther infusion reset pump
Ther/proph/diag inj sc/im
Immunization admin
Admin hepatitis b vaccine
CI
CH
CH
CH
CH
CH
S
I
S
S
S
S
S
APC
0437
0437
0437
0437
0437
2012
Payment
Rate
$34.81
$34.81
$34.81
$34.81
$34.81
S
S
S
S
S
2011
Pay Payment
Rate
Diff.
26.35
8.46
26.35
8.46
26.35
8.46
26.35
8.46
26.35
8.46
201
Behavioral Health Services
CPT and HCPCS code changes
Behavioral Health Services
Rev
Code
0510,
0513,
0920
0510,
0513,
0920
SI
2011
Ind Action Code
S
S
2012
Code Description
Therapeutic repetitive transcranial magnetic
DESC 90867
stimulation treatment; planning
Therapeutic repetitive transcranial magnetic
stimulation (TMS) treatment; initial, including
cortical mapping, motor threshold determination,
DESC
90867 delivery and management
203
Behavioral Health Services
Common side effects and adverse
health problems associated with
TMS include:
-- Headache
-- Lightheadedness
-- Discomfort from noise during
treatment
-- Pain at the site of stimulation
-- Tingling of facial muscles
-- Mild spasms or contractions of
facial muscles
204
Behavioral Health Services
Rev
Code
0510,
0513,
0920
0510,
0513,
0920
Rev
0510,
0513,
0920
2012
Code Description
Therapeutic repetitive transcranial magnetic
stimulation treatment; delivery and management, per
session
DESC 90868
Therapeutic repetitive transcranial magnetic
stimulation (TMS) treatment; subsequent delivery and
DESC
Description per session
2012 management,
Action 2011 90868
Therapeutic repetitive transcranial magnetic
stimulation (TMS) treatment; subsequent motor
threshold re-determination with delivery and
90869 management
ADD
2011
SI
Ind Action Code
S
S
SI
S
205
Behavioral Health Services
Rev
Code
0510,
0513,
0920
2012
Code Description
Therapeutic repetitive transcranial magnetic
stimulation treatment delivery and management per
session;
0161T
Note: Listed as deleted in 2012 but actually code was
deleted in 2011, reportable using 90867, 90868
2011
SI
Ind Action Code
DEL
206
Behavioral Health Services
Rev
Code
0918
0918
SI
2011
Ind Action Code
2012
Code Description
Developmental testing; limited (eg, Developmental
Screening Test II, Early Language Milestone
Q3 DESC 96110
Screen), with interpretation and report
Developmental screening, with interpretation and
Q3 DESC
96110 report, per standardized instrument form
207
Behavioral Health Services
Rev
Code
0918
0918
SI
2011
Ind Action Code
2012
Code Description
Developmental testing; extended (includes
assessment of motor, language, social, adaptive
and/or cognitive functioning by standardized
developmental instruments) with interpretation and
Q3 DESC 96111
report
Developmental testing, (includes assessment of
motor, language, social, adaptive, and/or cognitive
functioning by standardized developmental
Q3 DESC
96111 instruments) with interpretation and report
208
Behavioral Health Services
Rev
Code
051X
SI
2011
Ind Action Code
B
NEW
2012
Code Description
Development testing, with interpretation and report,
G0451 per standardized instrument form
209
Pulmonary and Respiratory
Therapy Services
CPT and HCPCS code changes
Pulmonary and Respiratory Services
• New instructional notes and definitions:
– Spirometry
– Vital capacity
– Flow-volume loop
– Plethysmography
– Nitrogen washout or helium dilution
– Impulse oscillometry
– Diffusion capacity
• Parenthetical notes provide additional guidance on
codes reportable or not reportable in combination
211
Pulmonary/Respiratory Therapy Services
Rev
Code
0460,
0480,
092X
0460,
0480,
092X
0460,
0480,
092X
0460,
0480,
092X
0460,
0480,
092X
SI
Ind
B
X
B
X
X
Action
DEL
DEL
2011
Code
2012
Code Description
93720
Plethysmography, total body; with
interpretation and report
93721
Plethysmography, total body; tracing only,
without interpretation and report
Plethysmography, total body;
DEL
93722
interpretation and report only
Plethysmography for determination of lung
volumes and, when performed, airway
NEW
94726 resistance
Pulmonary compliance study (eg,
plethysmography, volume and pressure
Existing
94750 measurements)
212
Pulmonary/Respiratory Therapy Services
Rev
Code
0460,
0480,
092X
0460,
0480,
092X
0460,
0480,
092X
0460,
0480,
092X
SI
Ind
2011
Code
Action
X
DEL
2012
Code Description
Functional residual capacity or residual
volume: helium method, nitrogen open
94240
circuit method, or other method
X
DEL
94260
X
NEW
X
NEW
Thoracic gas volume
Plethysmography for determination of lung
volumes and, when performed, airway
94726 resistance
Gas dilution or washout for determination
of lung volumes and, when performed,
distribution of ventilation and closing
94727 volumes
213
Pulmonary/Respiratory Therapy Services
Rev
Code
0460,
0480,
092X
0460,
0480,
092X
0460,
0480,
092X
SI
Ind
Action
X
DEL
X
NEW
X
NEW
2011
Code
2012
Code Description
Determination of maldistribution of inspired
gas: multiple breath nitrogen washout
curve including alveolar nitrogen or helium
94350
equilibration time
Plethysmography for determination of lung
volumes and, when performed, airway
94726 resistance
Gas dilution or washout for determination
of lung volumes and, when performed,
distribution of ventilation and closing
94727 volumes
214
Pulmonary/Respiratory Therapy Services
Rev
Code
0460,
092X
0460,
0480,
092X
0460,
0480,
092X
SI
Ind
2011
Code
Action
X
DEL
X
NEW
2012
Code Description
Determination of resistance to airflow,
94360
oscillatory or plethysmographic methods
Plethysmography for determination of lung
volumes and, when performed, airway
94726 resistance
X
NEW
94728 Airway resistance by impulse oscillometry
215
Pulmonary/Respiratory Therapy Services
Rev
Code
0460,
092X
0460,
0480,
092X
0460,
0480,
092X
SI
Ind
Action
X
DEL
X
NEW
X
NEW
2011
Code
2012
Code Description
Determination of airway closing volume,
94370
single breath tests
Plethysmography for determination of lung
volumes and, when performed, airway
94726 resistance
Gas dilution or washout for determination
of lung volumes and, when performed,
distribution of ventilation and closing
94727 volumes
216
Pulmonary/Respiratory Therapy Services
Rev
Code
0460,
092X
0460,
092X
0460,
092X
SI
Ind
2011
Code
Action
X
DEL
2012
Code Description
Carbon monoxide diffusing capacity (eg,
94720
single breath, steady state)
X
DEL
94725
X
NEW
Membrane diffusion capacity
Diffusing capacity (eg, carbon monoxide,
membrane) (List separately in addition to
94729 code for primaryprocedure)
217
Respiratory
Rev SI
Code Ind Action
0920,
092X
X
ADD
0920,
092X
X
ADD
2011
Code
2012
Code Description
Car seat/bed testing for airway integrity, neonate, with
continual nursing observation and continuous recording
of pulse oximetry, heart rate and respiratory rate, with
94780 interpretation and report; 60 minutes
Car seat/bed testing for airway integrity, neonate, with
continual nursing observation and continuous recording
of pulse oximetry, heart rate and respiratory rate, with
interpretation and report; each additional full 30
minutes (List separately in addition to code for primary
94781 procedure)
Do not report 94780 for less than 60 minutes
Will be used primarily for inpatient reporting prior to discharge
218
Payment Rate Comparison October 2011 to 2012
HCPCS
Code
94010
94011
94012
94375
94453
94681
Short Descriptor
Breathing capacity test
Spirometry up to 2 yrs old
Spirmtry w/brnchdil inf-2 yr
Respiratory flow volume loop
Hast w/oxygen titrate
Exhaled air analysis o2/co2
SI
X
X
X
X
X
X
APC
0367
0367
0367
0367
0367
0369
Relative
Weight
0.7420
0.7420
0.7420
0.7420
0.7420
2.6868
2012
Payment
Rate
$51.95
$51.95
$51.95
$51.95
$51.95
$188.12
N
a
2011
t Payment Payment
i
Rate
Diff
X
59.63
(7.68)
X
59.63
(7.68)
X
59.63
(7.68)
X
59.63
(7.68)
X
59.63
(7.68)
X
59.63
128.49
219
Supplies
Medical Devices
Implantables
HCPCS code changes
Transmittal 2296 – October 2011 Update of the Hospital
Outpatient Prospective Payment System (OPPS)
• New Device Pass-Through Categories
– It has been over a year since CMS introduced a
separately payable medical device
• C1749 Endoscope, retrograde imaging/illumination
colonoscope device (implantable)
–Two new categories as of October 1, 2011:
• C1830 – Power bone marrow bx needle
• C1840 – Telescopic intraocular lens
– One new Code as of January 1, 2012
• C1886 – Catheter extravascular tissue ablation, any
modality (insertable)
221
Transmittal 2296 – October 2011 Update of the Hospital
Outpatient Prospective Payment System (OPPS)
C1830 – Powered bone marrow
biopsy needle
• http://www.diagnosticpathology.org
/content/6/1/23
• Power driver and biopsy needle
components of the OnControl
powered bone marrow sampling
system
222
Transmittal 2296 – October 2011 Update of the Hospital
Outpatient Prospective Payment System (OPPS)
• Device utilizes a battery-powered drill to insert the bone
marrow needle into the iliac bone of adult patient with
minimal operator exertion.
– Resembles a small hand-held drill and drives a single
lumen needle set into the bone cavity. Needle set
consists of two parts: an outer cannula, 11 gauge x 4
inches long; and a bevel-tip inner stylet used to penetrate
the cortex of the bone.
– C1830, Revenue code 0272, 0278
223
Transmittal 2296 – October 2011 Update of the Hospital
Outpatient Prospective Payment System (OPPS)
• Since the introduction of the
Jamshidi needle in 1971
(shown), there has been no
substantial advancement in
marrow sampling
technology
224
Transmittal 2296 – October 2011 Update of the Hospital
Outpatient Prospective Payment System (OPPS)
• http://abcnews.go.com/Health/Vid
eo/videoLogin?id=3476757
• http://www.visoncareinc.net/
• The Implantable Telescope
Technology platform incorporates
wide-angle micro-optical lenses
in a Galilean telescope design.
Based on this proprietary
technology, VisionCare’s lead
product (Implantable Miniature
Telescope) along with the cornea,
enlarges images in front of the
eye approximately 2.2 or 2.7
times their normal size
(depending on the model used).
225
Transmittal 2296 – October 2011 Update of the Hospital
Outpatient Prospective Payment System (OPPS)
• The magnification allows central images to be projected
onto healthy perimacular areas of the retina instead of the
macula alone, where breakdown of photoreceptors and
loss of vision has occurred. This helps reduce the blind
spot caused as a result of macular degeneration disease.
• C1840, Revenue Code 0278
226
Transmittal 2296 – October 2011 Update of the Hospital
Outpatient Prospective Payment System (OPPS)
• CPT 66982 Extracapsular cataract removal with insertion
of intraocular lens prosthesis (1-stage procedure), manual
or mechanical technique (eg, irrigation and aspiration or
phacoemulsification), complex, requiring devices or
techniques not generally used in routine cataract surgery
(eg, iris expansion device, suture support for intraocular
lens, or primary posterior capsulorrhexis) or performed on
patients in the amblyogenic developmental stage or…..
227
Transmittal 2296 – October 2011 Update of the Hospital
Outpatient Prospective Payment System (OPPS)
• CPT 66984 Extracapsular cataract removal with insertion
of intraocular lens prosthesis (1 stage procedure), manual
or mechanical technique (eg, irrigation and aspiration or
phacoemulsification)
– CPT 66982 and 66984 group to APC 0246
• C1840 has a device offset amount of $221.71 to be deducted from
payment facility receives for surgical CPT code
228
Transmittal 2291, FY2012 Inpatient Prospective Payment
System
• AutoLITT – a minimally invasive MRI-guided laser tipped
catheter designed to destroy malignant brain tumors with
interstitial thermal energy causing immediate coagulation
and necrosis of diseased tissue.
– New Technology and add-on payment will be eligible until
December 2012. Because the 3-year anniversary date for the
AutoLITT will occur after FY2012, CMS will continue to make
new technology add-on payment until September 30, 2012
229
AutoLITT
230
Transmittal 2291, FY2012 Inpatient Prospective Payment
System
– HIM drives facility’s add-on reimbursement with the
assignment of:
• ICD-9-PCS 17.61, Laser Interstitial Thermal Therapy
(LITT) of lesion or tissue of brain under guidance
– Add-on Reimbursement Opportunity $5,300
231
Medical Supplies
Rev
Code
SI
Ind Action
0272
A
NEW
0272
A
NEW
0272
E
NEW
2011
Code
2012
Code
Description
Ostomy pouch, drainable, with extended
wear barrier attached, with filter, (1
A5056 piece), each
Ostomy pouch, drainable, with extended
wear barrier attached, with built in
A5057 convexity, with filter, (1 piece), each
Mechanical wound suction, disposable,
includes dressing, all accessories and
A9272 components, each
232
Payment Changes for Biological Wound Products
HCPCS
Short Descriptor
Code
C9360
C9361
C9362
C9363
C9364
SurgiMend, neonatal
NeuroMend nerve wrap
Implnt,bon void filler-strip
Integra Meshed Bil Wound Mat
Porcine implant, Permacol
2012
SI APC Payment
Rate
K 9360 $11.23
N
N
K 9363 $20.60
N
N 2011
a Payment
t
Rate
.G
11.44
G 239.46
G
51.87
.G
20.99
G
17.44
233
Durable Medical
Equipment/Supplies
Other Medical/Surgical Supplies
DME, Medical Supplies
Rev
Code
0290
SI
2011
Ind Action Code
E
DEL
0290
Y
NEW
0290
Y
NEW
0290
Y
NEW
E0571
2012
Code Description
Aerosol compressor, battery powered,
for use with small volume nebulizer
No replacement found
Manual wheelchair accessory, push
E0988 activiated power assist, Each
Power wheelchair accessory, Group
34 Non-Sealed Lead ACID battery,
E2358 each
Power wheelchair accessory, Group
34 Sealed Lead Acid Battery, Each
E2359 (e.g. Gel Cell, Absorbed Glassmat)
235
DME, Medical Supplies
Rev
Code
0274,
0290
0274,
0290
0274,
0290
SI
2011
Ind Action Code
A
DEL
L1500
A
DEL
L1510
A
DEL
L1520
2012
Code Description
Thoracic-hip-knee-ankle orthotic
(THKAO), mobility frame (Newington,
Parapodium types)
Thoracic-hip-knee-ankle orthotic
(THKAO), standing frame, with or
without tray and accessories
Thoracic-hip-knee-ankle orthotic
(THKAO), swivel walker
236
DME, Medical Supplies
Rev
Code
SI
2011
Ind Action Code
0290
Y
DEL
0290
Y
NEW
2012
Code Description
Shoulder-elbow orthotic (SEO), mobile
arm support attached to wheelchair,
balanced, adjustable, prefabricated,
L3964
includes fitting and adjustment
Wheelchair accessory, shoulder
elbow, mobile arm support attached to
E2626 wheelchair, balanced, adjustable
237
DME, Medical Supplies
Rev
Code
SI
2011
Ind Action Code
0290
Y
DEL
0290
Y
NEW
2012
Code Description
Shoulder-elbow orthotic (SEO), mobile
arm support attached to wheelchair,
balanced, adjustable Rancho type,
prefabricated, includes fitting and
L3965
adjustment
Wheelchair accessory, shoulder
elbow, mobile arm support attached to
wheelchair, balanced, adjustable
E2627 Rancho type
238
DME, Medical Supplies
Rev
Code
SI
2011
Ind Action Code
0290
Y
DEL
0290
Y
NEW
2012
Code Description
L3966
E2628
Shoulder-elbow orthotic (SEO), mobile
arm support attached to wheelchair,
balanced, reclining, prefabricated,
includes fitting and adjustment
Wheelchair accessory, shoulder
elbow, mobile arm support attached to
wheelchair, balanced, reclining
239
DME, Medical Supplies
Rev
Code
SI
2011
Ind Action Code
0290
Y
DEL
0290
Y
NEW
2012
Code Description
L3968
E2629
Shoulder-elbow orthotic (SEO), mobile
arm support attached to wheelchair,
balanced, friction arm support (friction
dampening to proximal and distal
joints), prefabricated, includes fitting
and adjustment
Wheelchair accessory, shoulder
elbow, mobile arm support attached to
wheelchair, balanced, friction arm
support (Friction dampening to
proximal and distal joints)
240
DME, Medical Supplies
Rev
Code
SI
2011
Ind Action Code
0290
Y
DEL
0290
Y
NEW
2012
Code Description
Shoulder-elbow orthotic (SEO), mobile
arm support, monosuspension arm
and hand support, overhead elbow
forearm hand sling support, yoke type
suspension support, prefabricated,
L3969
includes fitting and adjustment
Wheelchair accessory, shoulder
elbow, mobile arm support,
monosuspension arm and hand
support, overhead elbow forearm hand
E2630 sling support, Yoke type
241
DME, Medical Supplies
Rev
Code
SI
2011
Ind Action Code
0290
Y
DEL
0290
Y
NEW
2012
Code Description
Shoulder-elbow orthotic (SEO),
addition to mobile arm support,
L3970
elevating proximal arm
Wheelchair accessory, addition to
mobile arm support, elevating proximal
E2631 arm
242
DME, Medical Supplies
Rev
Code
0290
0290
2011
SI
Ind Action Code
Y
Y
DEL
NEW
L3972
2012
Code Description
Shoulder-elbow orthotic (SEO),
addition to mobile arm support, offset
or lateral rocker arm with elastic
balance control
Wheelchair accessory, addition to
mobile arm support, offset or lateral
E2632 rocker arm with elastic balance control
243
DME, Medical Supplies
Rev
Code
SI
2011
Ind Action Code
0290
Y
DEL
0290
Y
NEW
0274,
0290
A
DEL
2012
Code Description
Shoulder-elbow orthotic (SEO),
addition to mobile arm support,
L3974
supinator
Wheelchair accessory, addition to
E2633 mobile arm support, supinator
L4380
Pneumatic knee splint, prefabricated,
includes fitting and adjustment
244
DME, Medical Supplies
Rev
Code
0274,
0290
0274,
0290
SI
2011
Ind Action Code
A
A
DEL
NEW
L5311
2012
Code Description
Knee disarticulation (or through knee),
molded socket, external knee joints,
shin, SACH foot, endoskeletal system
Knee disarticulation (or through knee),
molded socket, single axis knee,
L5312 Pylon, Sach foot, Endoskeletal System
245
DME, Medical Supplies
Rev
Code
0274,
0290
0274,
0290
SI
2011
Ind Action Code
A
A
NEW
2012
Code Description
Terminal device, multiple articulating
digit, includes motor®, initial issue or
L6715 replacement
NEW
Electric hand, switch or myoelectric
controlled, independently articulating
digits, any grasp pattern or comination
L6880 of grasp patterns, includes motor(s)
246
DME, Medical Supplies
Rev
SI
Code Ind Action
0274,
0290 A DEL
0274,
0290 A DEL
0274,
0290 A DEL
0274,
0290
A
DEL
2011
Code
2012
Code Description
L7266
Servo control, Steeper or equal
L7272
Analogue control, UNB or equal
Proportional control, 6-12 volt, Liberty,
Utah or equal
Repair of prosthetic device, hourly rate
(excludes V5335 repair of oral or
laryngeal prosthesis or artificial larynx)
L7274
L7500
247
Neurology Services
CPT and HCPCS code changes
Sleep Medicine Testings
• Provided descriptions for reporting sleep testings:
– Actigraphy
– Attended
– Electrooculogram (EOG)
– Maintenance of wakefulness test (MWT)
– Multiple sleep latency test (MSLT)
– Peripheral arterial tonometry (PAT)
– Physiological measurement of sleep
– Polysomnography
– Sleep Staging
249
Neurology Services
Rev
Code
SI
Ind
Action
2011
Code
0920,
092X
Rev
S ADD
SI Action
2011
0920,
092X
S
ADD
2012
Code Description
Needle electromyography, each extremity, with
related paraspinal areas, when performed, done
with nerve conduction, amplitude and
latency/velocity study; limited (List separately in
95885 addition to code for primary procedure)
2012 Description
Needle electromyography, each extremity, with
related paraspinal areas, when performed, done
with nerve conduction, amplitude and
latency/velocity study; complete, five or more
muscles studied, innervated by three or more
nerves or four or more spinal levels (List
separately in addition to code for primary
95886 procedure)
Use 95885, 95886 in conjunction with 9590095904 Do not report 95885, 95886 in conjunction
with 95860-95864, 95870, 95905)
250
Neurology Services
Rev
Code
SI
Ind
0920,
092X
S
Action
ADD
2011
Code
2012
Code Description
Needle electromyography, non-extremity (cranial
nerve supplied or axial) muscle(s) done with nerve
conduction, amplitude and latency/velocity study
(List separately in addition to code for primary
95887 procedure)
Use 95887 in conjunction with 95900-95904. Do
not report 95887 in conjunction with 95867-95870,
95887 95905.
251
Neurology Services
Rev
Code
SI
Ind
Action
0920,
0929
S
DESC
2011
Code
2012
Code Description
Electronic analysis of implanted neurostimulator
pulse generator system (eg, rate, pulse
amplitude, pulse duration, configuration of wave
form, battery status, electrode selectability,
output modulation, cycling, impedance and
patient compliance measurements); simple or
complex brain, spinal cord, or peripheral (ie,
cranial nerve, peripheral nerve, sacral nerve,
neuromuscular) neurostimulator pulse
95970 generator/transmitter, without reprogramming
I
252
Neurology Services
Rev
Code
SI
Ind
Action
0920,
0929
S
DESC
2011
Code
2012
Code Description
Electronic analysis of implanted neurostimulator
pulse generator system (eg, rate, pulse
amplitude, pulse duration, configuration of wave
form, battery status, electrode selectability,
output modulation, cycling, impedance and
patient compliance measurements); simple
spinal cord, or peripheral (ie, peripheral nerve,
sacral nerve, neuromuscular) neurostimulator
pulse generator/transmitter, with intraoperative or
95971 subsequent programming
253
Neurology Services
Rev
Code
SI
Ind
Action
0920,
0929
S
DESC
2011
Code
2012
Code Description
Electronic analysis of implanted neurostimulator
pulse generator system (eg, rate, pulse
amplitude, pulse duration, configuration of wave
form, battery status, electrode selectability,
output modulation, cycling, impedance and
patient compliance measurements); complex
spinal cord, or peripheral (ie, peripheral nerve,
sacral nerve, neuromuscular) (except cranial
nerve) neurostimulator pulse
generator/transmitter, with intraoperative or
95972 subsequent programming, first hour
254
Neurology Services
Rev
Code
SI
Ind
Action
0920,
0929
S
DESC
2011
Code
2012
Code Description
Electronic analysis of implanted neurostimulator
pulse generator system (eg, rate, pulse
amplitude, pulse duration, configuration of wave
form, battery status, electrode selectability,
output modulation, cycling, impedance and
patient compliance measurements); complex
spinal cord, or peripheral (ie, peripheral nerve,
sacral nerve, neuromuscular) (except cranial
nerve) neurostimulator pulse
generator/transmitter, with intraoperative or
subsequent programming, each additional 30
minutes after first hour (List separately in addition
95973 to code for primary procedure)
255
Neurology Services
Rev
Code
SI
Ind
Action
0920,
0929
S
DESC
2011
Code
2012
Code Description
Electronic analysis of implanted neurostimulator
pulse generator system (eg, rate, pulse
amplitude, pulse duration, configuration of wave
form, battery status, electrode selectability,
output modulation, cycling, impedance and
patient compliance measurements); complex
cranial nerve neurostimulator pulse
generator/transmitter, with intraoperative or
subsequent programming, with or without nerve
95974 interface testing, first hour
256
Neurology Services
Rev
Code
SI
Ind
Action
0920,
0929
S
DESC
2011
Code
2012
Code Description
Electronic analysis of implanted neurostimulator
pulse generator system (eg, rate, pulse
amplitude, pulse duration, configuration of wave
form, battery status, electrode selectability,
output modulation, cycling, impedance and
patient compliance measurements); complex
cranial nerve neurostimulator pulse
generator/transmitter, with intraoperative or
subsequent programming, each additional 30
minutes after first hour (List separately in addition
95975 to code for primary procedure)
257
Neurology Services
Rev
Code
SI
Ind
0922,
0929
S
0922,
0929
S
ADD
2012
Code Description
Short-latency somatosensory evoked potential
study, stimulation of any/all peripheral nerves or
skin sites, recording from the central nervous
95938 system; in upper and lower limbs
ADD
Central motor evoked potential study (transcranial
95939 motor stimulation); upper and lower limbs
Action
2011
Code
258
Neurology Services
Rev
Code
SI
Ind
0920,
0929
S
0920,
0929
S
ADD
2012
Code Description
Percutanous or open implantation of
neurostimulator electrode array(s), subcutaneous
(peripheral subcutaneous field stimulation),
including imaging guidance, when performed,
cervical, thoracic or lumbar; for trial, including
0282T removal at the conclusion of trial period
ADD
Percutanous or open implantation of
neurostimulator electrode array(s), subcutaneous
(peripheral subcutaneous field stimulation),
including imaging guidance, when performed,
cervical, thoracic or lumbar; permanent, with
0283T implantation of a pulse generator
Action
2011
Code
Included in Interventional Radiology Section, discussed earlier
259
Neurology Services
Rev
Code
SI
Ind
0920,
0929
T
ADD
0920,
0929
S
ADD
Action
2011
Code
2012
Code Description
Revision or removal of pulse generator or
electrodes, including imaging guidance, when
performed, including addition of new electrodes,
0284T when performed
Electronic analysis of implanted peripheral
subcutaneous field stimulation pulse generator,
0285T with reprogramming when performed
260
Clinic/Outpatient Departments
CPT and HCPCS code changes
Clinic/Outpatient Departments
• Revised paragraphs in section entitled:
–“Immunization Administration for
Vaccines/Toxoids”
• In 2011 states “patient and family”
• In 2012 states “patient/family” in all locations
–Clarification provided for multi-valent antigens
and conjugates or adjuvants contained in
vaccines
262
Clinic/Outpatient Departments
Rev
Code
SI
2011
Ind Action Code
0771
B
0771
B
2012
Code Description
Immunization administration through 18 years of age via any
route of administration, with counseling by physician or other
qualified health care professional; first vaccine/toxoid
DESC 90460
component
Immunization administration through 18 years of age via any
route of administration, with counseling by physician or other
qualified health care professional; first or only component
DESC
90460 of each vaccine or toxoid administered
263
Clinic/Outpatient Departments
Rev
Code
0771
0771
Rev
0771
2012
Code Description
Immunization administration through 18 years of age via any
route of administration, with counseling by physician or other
qualified health care professional; each additional
vaccine/toxoid component (List separately in addition to
code for primary procedure)
B DESC 90461
Immunization administration through 18 years of age via any
route of administration, with counseling by physician or other
qualified health care professional; each additional vaccine or
toxoid administered (List separately in addition to code for
procedure)
B DESC
Description
2012 primary
Action 2011 90461
SI
H1N1 immunization administration (intramuscular,
intranasal), including counseling when performed
90470
DEL
2011
SI
Ind Action Code
CPT 90470 listed as deleted in Appendix B
Transmittal #2174, effective 4/1/11 listed both CPT 90470 and 90663 as
being deleted, effective 1/1/2011
264
Clinic/Outpatient Departments
Rev
Code
051X,
0761,
094X
051X,
0761,
094X
051X,
0761,
094X
SI
2011
Ind Action Code
N DEL
92070
2012
Code Description
Fitting of contact lens for treatment of disease, including
supply of lens
N NEW
Fitting of contact lens for treatment of occular surface
92071 disease
N NEW
Fitting of contact lens for management of keratoconus, initial
92072 fitting
For subsequent fittings, report using Evaluation and Management
services or General Ophthalmological services
265
Clinic/Outpatient Departments
Rev
Code
051X,
0761,
092X
051X,
0761,
092X
SI
2011
Ind Action Code
2012
Code Description
S
DEL
92120
Tonography with interpretation and report, recording
indentation tonometer method or perilimbal suction method
S
DEL
92130
Tonography with water provocation
Single episode tonometry is a component of general ophthalmological
Services, reported with E/M services, e.g.:
92002-92004,. 92012-92014, 92100, 99211-99480
266
Clinic/Outpatient Departments
Rev
Code
0335,
094X
0335,
094X
SI
2011 2012
Ind Action Code Code Description
Refilling and maintenance of implantable pump or reservoir
for drug delivery, spinal (intrathecal, epidural) or brain
S DESC 95990
(intraventricular);
Refilling and maintenance of implantable pump or reservoir
for drug delivery, spinal (intrathecal, epidural) or brain
(intraventricular), includes electronic analysis of pump,
S DESC
95990 when performed;
267
Clinic/Outpatient Departments
Rev
Code
0335,
094X
0335,
094X
SI
2011 2012
Ind Action Code Code Description
Refilling and maintenance of implantable pump or reservoir
for drug delivery, spinal (intrathecal, epidural) or brain
S DESC 95991
(intraventricular); administered by physician
Refilling and maintenance of implantable pump or reservoir
for drug delivery, spinal (intrathecal, epidural) or brain
(intraventricular), includes electronic analysis of pump,
S DESC
95991 when performed; requiring physician's skill
268
Clinic/Outpatient Departments
Rev
SI
2011 2012
Code Ind Action Code Code Description
036X,
051X,
Rhinophototherapy, intranasal application of ultraviolet and
0761 T DEL 0168T
visible light, bilateral
Replacement CPT code 30999
Rhinophototherapy for the treatment of allergies is not medically
necessary due to insufficient clinical evidence in the peer-reviewed
medical literature. Medicare does not have a National Coverage
Determination or a Local Coverage Determination for
Rhinophototherapy.
269
Clinic/Outpatient Departments
Rev
Code
051X,
0761
051X,
0761
051X,
0761
051X,
0761
051X,
0761
SI
2011
Ind Action Code
E
DEL
11975
DEL
Insertion, implantable contraceptive capsules
11981 Insertion, non-biodegradable drug delivery implant
X Exist
E
2012
Code Description
11977
Removal with reinsertion, implantable contraceptive
capsules
X Exist
11981 Insertion, non-biodegradable drug delivery implant
T Exist
11976 Removal, implantable contraceptive capsules
270
Clinic/Outpatient Departments
Rev
Code
051X,
076X
051X,
076X
SI
2011
Ind Action Code
2012
Code Description
Electronic analysis of programmable, implanted pump
for intrathecal or epidural drug infusion (includes
evaluation of reservoir status, alarm status, drug
S DESC 62367
prescription status); without reprogramming
Electronic analysis of programmable, implanted pump
for intrathecal or epidural drug infusion (includes
evaluation of reservoir status, alarm status, drug
S DESC
62367 prescription status); without reprogramming or refill
271
Clinic/Outpatient Departments
Rev
Code
051X,
076X
051X,
076X
SI
2011
Ind Action Code
S
S
2012
Code Description
ADD
Electronic analysis of programmable, implanted pump
for intrathecal or epidural drug infusion (includes
evaluation of reservoir status, alarm status, drug
62369 prescription status); with reprogramming and refill
ADD
Electronic analysis of programmable, implanted pump
for intrathecal or epidural drug infusion (includes
evaluation of reservoir status, alarm status, drug
prescription status); with reprogramming and refill
62370 (requiring physician's skill)
272
Clinic/Outpatient Departments
Rev
Code
051X,
076X
SI
Ind
S
Action
ADD
2011
Code
2012
Code Description
Transcutaneous electrical modulation pain
reprocessing (eg, scrambler therapy), each
treatment session (includes placement of
0278T electrodes)
A type of treatment for nerve pain that uses electrodes placed
on the skin. Electricity is carried from the electrodes through
the skin and blocks the pain. The pain may be caused by
physical injury, infection, toxic substances, and certain diseases
or drugs, including anticancer drugs.
273
Clinic/Outpatient Departments
Rev SI
2011
Cod Ind Action Code
0949 A
DEL G9041
0949 A
DEL G9042
0949 A
DEL G9043
0949 A
DEL G9044
2012
Code Description
Rehabilitation services for low vision by qualified occupational
therapist, direct one-on-one contact, each 15 minutes
Rehabilitation services for low vision by certified orientation
and mobility specialists, direct one-on-one contact, each 15
minutes
Rehabilitation services for low vision by certified low vision
rehabilitation therapist, direct one-on-one contact, each 15
minutes
Rehabilitation services for low vision by certified low vision
rehabilitation teacher, direct one-on-one contact, each 15
minutes
274
GI Laboratory
CPT and HCPCS code changes
GI Laboratory
Rev
SI
2011 2012
Code Ind Action Code Code Description
0750,
092X
0750,
092X
Esophageal motility (manometric study of the
esophagus and/or gastroesophageal junction) study
X DESC 91010
with interpretation and report; 2-dimensional data
Esophageal motility (manometric study of the
esophagus and/or gastroesophageal junction) study
X DESC
91010 with interpretation and report
276
GI Laboratory
Rev
SI
2011 2012
Code Ind Action Code Code Description
Esophageal motility (manometric study of the
0750,
esophagus and/or gastroesophageal junction) study;
092X X DEL
91012
with acid perfusion studies
Code Listed as “Deleted” in 2012
Code actually deleted January 2011
Replacement codes see 91013 with 91010
277
GI Laboratory
Rev
SI
2011 2012
Code Ind Action Code Code Description
Esophageal motility (manometric study of the
esophagus and/or gastroesophageal junction) study
with interpretation and report; with stimulation or
051X,
perfusion during 2-dimensional data study (eg,
0750,
stimulant, acid or alkali perfusion) (List separately in
092X X DESC 91013
addition to code for primary procedure)
Esophageal motility (manometric study of the
esophagus and/or gastroesophageal junction) study
051X,
with interpretation and report; with stimulation or
0750,
perfusion(eg, stimulant, acid or alkali perfusion) (List
092X X DESC
91013 separately in addition to code for primary procedure)
278
GI Laboratory
Rev
SI
2011 2012
Code Ind Action Code Code Description
0750,
092X
0750,
092X
Esophageal motility (manometric study of the
esophagus and/or gastroesophageal junction) study
with interpretation and report; with 3-dimensional
X DESC 0240T
high resolution esophageal pressure topography
Esophageal motility (manometric study of the
esophagus and/or gastroesophageal junction) study
with interpretation and report; with high resolution
X DESC
0240T esophageal pressure topography
279
GI Laboratory
Rev
SI
2011 2012
Code Ind Action Code Code Description
0750,
092X
0750,
092X
Esophageal motility (manometric study of the
esophagus and/or gastroesophageal junction) study
with interpretation and report; with stimulation or
perfusion during 3-dimensional high resolution
esophageal pressure topography study (eg,
stimulant, acid or alkali perfusion) (List separately in
X DESC 0241T
addition to code for primary procedure)
Esophageal motility (manometric study of the
esophagus and/or gastroesophageal junction) study
with interpretation and report; with stimulation or
perfusion during high resolution esophageal pressure
topography study (eg, stimulant, acid or alkali
perfusion) (List separately in addition to code for
X DESC
0241T primary procedure)
280
GI Laboratory
Rev
SI
2011 2012
Code Ind Action Code Code Description
Bronchoscopic bronchial thermoplasty with image
0750,
guidance (if performed), radiofrequency ablation of
092X T DEL C9730
airway smooth muscle, 1 lobe
Bronchoscopy, rigid or flexible, including fluoroscopic
0750,
guidance, when performed; with bronchial
092X
T NEW
Rev
SI
Action 2011 0276T
2012 thermoplasty,
Description 1 lobe
0750,
092X
0750,
092X
Bronchoscopic bronchial thermoplasty with image
C9731
guidance (if performed), radiofrequency ablation of
T DEL
`
airway smooth muscle, 2 or more lobes
Bronchoscopy, rigid or flexible, including fluoroscopic
guidance, when performed; with bronchial
T NEW
0277T thermoplasty, 2 or more lobes
http://www.btforasthma.com/video/procedure.htm
281
GI Laboratory
Rev SI
2011 2012
Code Ind Action Code Code Description
0750,
092X T ADD
Anoscopy, with delivery of thermal energy to the
0288T muscle of the anal canal (eg, for fecal incontinence)
282
Rehabilitation Services:
Audiology, Physical
Speech and Occuptational
Therapy
CPT and HCPCS code changes
Rehabilitation Services – Audiology
Rev
Code
0471
SI
Ind Action
E
ADD
2011
Code
2012
Code Description
Evoked otoacoustic emissions, screening
(qualitative measurement of distortion product or
transient evoked otoacoustic emissions),
92558 automated analysis
THIS MAY BE THE NEW "NEWBORN HEARING SCREENING" TEST CODE, MOST
HAVE USED THE CURRENT 92585
284
Rehabilitation Services - Audiology
Rev
Code
SI
Ind Action
0471
X DESC
0471
X DESC
2011
Code
2012
Code Description
Evoked otoacoustic emissions; limited (single
stimulus level, either transient or distortion
92587
products)
Distortion product evoked otoacoustic
emissions; limited evaluation to confirm the
presence or absence of hearing disorder, 3-6
frequencies) or transient evoked otoacoustic
92587 emissions, with interpretation and report
285
Rehabilitation Services - Audiology
Rev
Code
SI
Ind Action
0471
X DESC
0471
X DESC
2011
Code
2012
Code Description
Evoked otoacoustic emissions; comprehensive
or diagnostic evaluation (comparison of
transient and/or distortion product
otoacoustic emissions at multiple levels and
92588
frequencies)
Distortion product evoked otoacoustic
emissions; comprehensive or diagnostic
evaluation (quantitative analysis of outer hair
cell function by cochlear mapping,
minimum of 12 frequencies), with
92588 interpretation and report
286
Rehabilitation Services – Audiology
Rev
Code
SI
Ind Action
0471
N DESC
0471 N
DESC
2011
Code
2012
Code Description
Evaluation of central auditory function, with
92621
report; each additional 15 minutes
Evaluation of central auditory function, with
report; each additional 15 minutes (List
separately in addition to code for primary
92621 procedure)
287
Rehabilitation Services
Rev
Code
051X,
076X,
0420,
0430
051X,
076X,
0420,
0430
SI
2011 2012
Ind Action Code Code Description
X
NEW
X
NEW
Extracorporeal shock wave for integumentary
wound healing, high energy, including topical
0299T application and dressing care; initial wound
Extracorporeal shock wave for integumentary
wound healing, high energy, including topical
application and dressing care; each additional
wound (List separately in addition to code for
0300T primary procedure)
Effective January 1, 2012, not printed in new code book. See also
0019T, 0101T and 0102T
Discussed previously in Wound Clinic section
288
Rehabilitation Services – Speech Therapy
Rev
Code
SI
Ind Action
0444
A
DESC
0444
A
DESC
2011
Code
2012
Code Description
Evaluation for prescription of non-speechgenerating augmentative and alternative
92605
communication device
Evaluation for prescription of non-speechgenerating augmentative and alternative
communication device, face-to-face with the
92605 patient; first hour
289
Rehabilitation Services – Speech Therapy
Rev
Code
0444
SI
Ind Action
A
ADD
2011
Code
2012
Code Description
Evaluation for prescription of non-speechgenerating augmentative and alternative
communication device, face-to-face with the
patient; each additional 30 minutes (List
separately in addition to code for primary
92618 procedure)
290
Rehabilitation Services-Physical/Occupational Therapy
Rev
Code
042X,
043X,
042X,
043X,
SI
Ind Action
S
DESC
S
DESC
2011
Code
2012
Code Description
Application of multi-layer venous wound
29581
compression system, below knee
Application of multi-layer compression system;
29581 leg (below knee), including ankle and foot
291
Rehabilitation Services-Physical/Occupational Therapy
Rev
Code
042X,
043X,
042X,
043X,
042X,
043X,
SI
Ind Action
S
ADD
S
ADD
S
ADD
2011
Code
2012
Code Description
Application of multi-layer compression system;
thigh and leg, including ankle and foot, when
29582 performed
Application of multi-layer compression system;
29583 upper arm and forearm
Application of multi-layer compression system;
29584 upper arm, forearm, hand, and fingers
292
Miscellaneous Codes
CPT and HCPCS code changes
Nursery, Nursing Procedures
Rev SI
Code Ind Action
0761
N
ADD
0761
N
ADD
2011
Code
2012
Code Description
Total body systemic hypothermia, per day, in the
0260T neonate 28 days of age or younger
Selective head hypothermia, per day, in the neonate 28
0261T days or younger
Codes were introduced January, 2011. Printed code in new code
book, listed as new code for 2012.
294
Nursing Procedures
Rev SI
2011 2012
Code Ind Action Code Code Description
Near-infrared guidance for vascular access requiring
real-time digital visualization of subcutaneous
vasculature for evaluation of potential access sites and
092X N ADD
0287T vessel patency
295
Nursing Procedures
296
Nursing Procedures
Rev SI
Code Ind Action
0920,
092X
X
ADD
0920,
092X
X
ADD
2011
Code
2012
Code Description
Car seat/bed testing for airway integrity, neonate, with
continual nursing observation and continuous recording
of pulse oximetry, heart rate and respiratory rate, with
94780 interpretation and report; 60 minutes
Car seat/bed testing for airway integrity, neonate, with
continual nursing observation and continuous recording
of pulse oximetry, heart rate and respiratory rate, with
interpretation and report; each additional full 30
minutes (List separately in addition to code for primary
94781 procedure)
297
Surgery Procedures
CPT and HCPCS code changes
Skin Substitute Applications
• Classification of repairs:
–Simple repair
–Intermediate repair
–Complex repair
• When more than one classification of wounds is
repaired, list the more complicated as the
primary procedure and the less complicated as
the secondary procedure, using modifier 59
299
In-Patient Only Procedure Revisions, 2012
HCPCS
Short Descriptor
Code
G0406
G0407
G0408
G0425
G0426
G0427
Inpt/tele follow up 15
Inpt/tele follow up 25
Inpt/tele follow up 35
Inpt/ED teleconsult30
Inpt/ED teleconsult50
Inpt/ED teleconsult70
Relative Payment
SI APC
Weight Rate
B
B
B
B
B
B
Inpatient
Only for
2011
G C
G C
G C
G C
G C
G C
300
In-Patient Only Procedure Revisions, 2012
HCPCS
Short Descriptor
Code
20930
20931
21346
22551
22554
35045
43281
43770
54650
0184T
Sp bone algrft morsel add-on
Sp bone algrft struct add-on
Treat nose/jaw fracture
Neck spine fuse&remov bel c2
Neck spine fusion
Repair defect of arm artery
Lap paraesophag hern repair
Lap place gastr adj device
Orchiopexy (Fowler-Stephens)
Exc rectal tumor endoscopic
Inpatient
Only for
2011
C
C
$1,742.66
C
$3,552.21
C
$3,552.21
C
$2,181.03
C
$5,010.75
C
$3,356.53
C
$2,305.58
C
0
$1,711.07
C
1
Relative Payment
SI APC
Weight Rate
N
N
T
T
T
T
T
T
T
T
254
208
208
93
132
131
154
149
24.89
50.734
50.734
31.151
71.566
47.939
32.929
24.438
301
New Procedures for 2012 Introduced as SI of “C”
HCPCS
Code
22633
22634
32096
32097
32098
32505
32506
32507
32666
32667
Short Descriptor
SI
Lumbar spine fusion combined
Spine fusion extra segment
Open wedge/bx lung infiltr
Open wedge/bx lung nodule
Open biopsy of lung pleura
Wedge resect of lung initial
Wedge resect of lung add-on
Wedge resect of lung diag
Thoracoscopy w/wedge resect
Thoracoscopy w/w resect addl
C
C
C
C
C
C
C
C
C
C
HCPCS
Code
32668
32669
32670
32671
32672
32673
32674
0281T
0293T
0294T
Short Descriptor
SI
Thoracoscopy w/w resect diag
Thoracoscopy remove segment
Thoracoscopy bilobectomy
Thoracoscopy pneumonectomy
Thoracoscopy for lvrs
Thoracoscopy w/thymus resect
Thoracoscopy lymph node exc
Laa closure w/implant
Ins lt atrl press monitor
Ins lt atrl press mont addon
C
C
C
C
C
C
C
C
C
C
302
Chargemaster Revision Process
• Utilize Current CDM
– Review all procedures
– Revise as needed:
• Additions
• Deletions
• HCPCS code changes
• Revenue code changes
• Descriptor revisions
– Update encounter
forms/input documents
– Data transfer issues
303
Coding Decisions
• Share Chargemaster with coding staff
– Eliminates duplicate work
– Avoids potential double reporting
– Assures continuity of reporting procedures and proper revenue
304
Final Thoughts
• Embrace the future……
– Look forward to updating the Chargemaster
• New challenges
• New codes
• New reimbursement opportunities???
• No one is doing “everything” correctly
305
Final Thoughts
• Read parenthetical statements
– Green font
• Refer to “Coding Tips”
– Read all paragraphs preceding sections
• Update Charge tickets or orderable screens
• Review productivity measures
• Educate
• Continually monitor gross revenue charges
– Monitor Revenue Capture processes for vulnerable clinical areas
306
Final Thoughts
• Mastering change is key element
for success
• 2012 offers new challenges
–Good luck!!!
307
Biography
• Glenda J. Schuler, RHIT, CPC, CPC-H
– glenda.schuler@optum.com
– Senior chargemaster consultant for Ingenix
– Over 30 years of experience in billing, coding,
chargemaster, CPT coding
– Past National speaker for AAPC, AHIMA, state
hospital associations, state HIMA chapters, VHA,
HFMA, Ingenix and other organizations specific for:
– Ambulatory payment classifications
– Chargemasters
– OCE Editor and CCI reporting
– Modifiers
308