Reimbursement Advisor

The new year brings refinements to CPT and Medicare codes

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New codes, deleted codes, and clarification of just who is a qualified health-care provider are some of the changes that occurred on January 1, 2013


Ms. Witt reports no financial relationships relevant to this article.

Among changes to Current Procedural Terminology (CPT) that took effect on January 1 are several of interest to our specialty:

  • the addition of “typical” times to the evaluation and management (E/M) codes for same-day admission and discharge
  • a new code for bladder injection
  • bundling of imaging guidance associated with percutaneous implantation of a neurostimulator electrode array, if performed, using code 64561, Percutaneous implantation of neurostimulator electrode array; sacral nerve (transforaminal placement).

In addition, CPT made it clear that all E/M codes can be reported by qualified nonphysician health-care providers, as well as physicians. As for Medicare, coding for administration of depot medroxyprogesterone acetate (Depo-Provera) has been modified, as has the billing process for interpretation of ultrasonography performed outside of the office.

Because of requirements in the Health Insurance Portability and Accountability Act (HIPAA), insurers were required to accept the new codes and revisions on January 1.

Providers can now characterize their level of service by how long it took to provide

As I mentioned, typical times have been added to the set of observation and inpatient care codes that involve admission and discharge on the same date of service. Until now, these codes did not have a pre-assigned typical time, and the provider had to select the level of service based solely on three key components: history, examination, and medical decision-making. The addition of times allows the provider to select the level of service based on counseling or coordination of care, if that activity dominated the visit.

The typical times are:

  • 99234, 40 minutes
  • 99235, 50 minutes
  • 99236, 55 minutes.

Chemodenervation of the bladder gets its own code

A new code, 52287, cystourethroscopy, with injection(s) for chemodenervation of the bladder, has been added to CPT. This procedure is performed to treat idiopathic overactive bladder that can’t be managed any other way. It typically involves the injection of botulinum. Before January 1, this procedure was reported using codes 52000 and 64614, but this approach represented an inexact match.

Payers will be looking closely at diagnostic coding for this procedure. The most frequently accepted diagnostic codes are:

  • 596.51, hypertonicity of bladder
  • 596.54, neurogenic bladder NOS
  • 596.55, detrusor sphincter dyssynergia
  • 596.59, other functional disorder of bladder
  • 788.41, urinary frequency.

Because costs will vary, depending on the chemotoxin used, the agent may be reported separately using the descriptive “J” code or another Medicare-designated alphanumeric code, such as J0585, injection of botulinum toxin type A, 1 unit.

Qualified providers now include nonphysicians as well as physicians

CPT has clarified that all E/M codes can be reported not only by physicians but by qualified nonphysicians as well.

CPT also changed wording in each of the codes so that the use of counseling time applies to all providers when counseling dominates the visit. In other words, if a payer allows someone other than a physician to provide and bill for a service, the CPT E/M codes can be used by all providers who qualify and have documented the service. These changes have no effect on the codes themselves.

Please note, however, that registered nurses and licensed practical nurses are not normally recognized as billing providers and will still be restricted to code 99211, Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, with this code, presenting problems are minimal. Typically, 5 minutes are spent performing or supervising these services. This code is often referred to as the “nurse-only” code.

As a result of this clarification, references to physicians have been removed from CPT code 59300, Episiotomy or vaginal repair, by other than attending. This change signifies that this code may be reported by any qualified provider who did not perform the delivery or was not covering for a physician group who billed for the delivery.

Three new codes for the flu vaccine

Two of the new codes are CPT codes, and the other is for Medicare:

  • 90653, Influenza vaccine, inactivated, subunit, adjuvanted, for intramuscular use
  • 90672, Influenza virus vaccine, live, for intranasal use
  • Q2034, Agriflu.

Keep in mind that the administration of the flu vaccine is reported differently for Medicare, compared with private payers. Administration code G0008 and diagnosis code V04.81 would be reported in conjunction with the appropriate vaccine code for Medicare. CPT requires that code 90471 be reported for administration.

CPT also revised all flu vaccine codes (90655–90660) to include the term “trivalent” to signify that all flu vaccines are made up of three strains of the virus.

Next Article:

Dr. Raul Ruiz goes to Washington

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