Vol. 16 •Issue 3 • Page 6
Review New ’06 Surgical Codes, Guidelines
This month’s CCS Prep! column reviews updated codes and guidelines for CPT outpatient surgical coding. The review is for CPT procedure coding issues only and excludes ICD-9-CM volume 3 and diagnosis coding. Please review the previous two CCS Prep! columns for information on the latest updates for the ICD-9-CM coding system. The issues discussed here will focus primarily on those coding scenarios most likely to occur in hospital outpatient settings. This article will only briefly cover skin replacement, skin substitute and revised skin grafting guidelines; these topics were covered in the Dec. 5, 2005 CCS Prep! column.
New parenthetical guidelines were added to CPT 2006 that pertain to the following codes:
11004 Debridement for necrotizing soft tissue infection; external genitalia & perineum
11005 abdominal wall
11006 external genitalia, perineum and abdominal wall
(When insertion of mesh is used for closure, use 49568)
The new guideline indicates that code 49568 (Implementation of mesh or other prosthesis for incisional or ventral hernia repair) may be used with the debridement codes listed above if mesh is used during the procedure. This illustrates the importance of fully understanding CPT guidelines and revisions because code 49568’s terminology does not indicate that this code would typically be used for debridement services.
As noted above, extensive revisions were made to the skin grafting section of CPT, with new codes for skin substitute products currently available and widely used throughout the country. It’s important for coders to note that these new codes may be used for a variety of conditions and are not restricted for use for burn cases only. Coders should review the Dec. 5, 2005, CCS Prep! column and ensure that they understand and can differentiate between autografts, allografts and xenografts and that they also understand the differences between skin replacements and skin substitutes.
The surgical preparation codes (listed below) have also been revised for 2006. The codes include:
15000 Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture; first 100 sq cm or one percent of body area of infants and children
15001 each additional 100 sq cm or each additional one percent of body area of infants and children
The phrase “incisional release of scar contracture” was added to these codes to indicate that an excisional release procedure is not necessary to assign the code(s) for skin grafting preparation services.
New code 28890 (Extracorporeal shock wave, high energy, performed by a physician, requiring anesthesia other than local, including ultrasound guidance, involving the plantar fascia) is now available for assignment for plantar fascia extracorporeal shock wave lithotripsy (ESW) services. This procedure was previously reported with Category III code 0020T or HCPCS code C9721, but has now met criteria for assignment to its own CPT code.
To assign this code, the documentation must indicate that high energy was utilized, the service must be performed by a physician using non-local anesthetic and the code includes ultrasound guidance, which should not be reported separately.
Further exclusions were added to several of the knee arthroscopy CPT codes to indicate that arthroscopic removal of foreign bodies (29874) and/or debridement or shaving of articular cartilage (29877) should not be reported separately unless performed in a separate compartment. When these services are performed in conjunction with arthroscopic osteochondral and meniscal grafting codes (29866, 29867 and 29868), the coder should review the documentation carefully before assigning 29874 and/or 29877. This guideline is consistent with others released by both the American Medical Association (AMA) and the Centers for Medicare and Medicaid Services (CMS) concerning unbundling of the knee arthroscopy codes.
Endoscopic sinus surgery is one of the most commonly performed types of ambulatory surgery throughout the U.S. today. To perform endoscopic procedures on the sinuses the inferior turbinate is accessed. CPT 2006 contains clarification indicating that if an inferior turbinectomy or other minor inferior turbinate procedure (represented by codes 30130, 30140, 30801, 30802 and 30930) is performed in association with an ethmoidectomy, it’s inclusive of the minor turbinate service, which should not be reported separately. The vast majority of procedures performed on a turbinate involve an inferior turbinectomy, which is typically performed for turbinate hypertrophy causing airway obstruction. The middle and superior turbinates are rarely treated with cautery and/or ablation nor laterally fractured. If these procedures are actually performed on the middle or superior turbinate and clearly documented as such, the revised CPT guidelines indicate that unlisted code 30999 should be reported.
Editorial revisions were also made to the laryngoscopy codes listed below to indicate that the codes include the use of both the operating microscope and the operating telescope. If documentation reflects the use of both during the same operative episode, the code is reported only once.
• 31526 Laryngoscopy, direct, with or without tracheoscopy; diagnostic, with operating microscope
• 31531 Laryngoscopy, direct, operative, with foreign body removal; with operating microscope
• 31536 Laryngoscopy, direct, operative, with biopsy; with operating microscope
• 31541 Laryngoscopy, direct, operative, with excision of tumor and/or stripping of vocal cords or epiglottis; with operating microscope
• 31561 Laryngoscopy, direct, operative, with arytenoidectomy; with operating microscope
• 31571 Laryngoscopy, direct, with injection into vocal cord(s), therapeutic; with operating microscope
In 2006, new code 36598 is available for contrast injection for radiologic evaluation of an existing central venous access device. The code includes fluoroscopy, which should not be reported separately, and the new code should not be reported separately with codes for mechanical thrombectomy services (36595 and 36596).
There are five new transcatheter procedure codes that represent mechanical thrombectomy services, differentiated by arterial vs. venous procedures. For these codes, thrombectomy is defined as the percutaneous removal of a thrombus (blood clot) from peripheral vessels. Coders should ensure that they don’t confuse mechanical thrombectomy procedures from percutaneous transluminal angioplasty (PTA) procedures, which treat the vessel wall, but do not remove the thrombus from a vessel.
In the mechanical thrombectomy procedures, devices are used that are specifically for mechanically breaking up, macerating and/or removing the thrombus from a non-coronary vessel. These services may be performed concurrently with arterial thrombolytic infusion therapy, which should be reported separately.
For arterial procedures, three new codes were developed:
• 37184: for primary treatment of the initial vessel
• 37185: add-on code for primary treatment of the second and all subsequent vessels within the same vascular family
• 37186: secondary procedure (also known as a “rescue” mechanical thrombectomy)
Primary treatment means that the pre-treatment planning, performance of the procedure and the post-procedure evaluation is focused on providing this mechanical thrombectomy service. Other interventions may be provided, but not until after this treatment has been performed. A secondary procedure is always performed in conjunction with another percutaneous intervention (e.g., PTA or stent placement). Typically, a small amount of clot is present in the lesion and needs to be removed prior to the PTA or stent procedure. The pre- and post-evaluation services would not be considered to be focused on the thrombectomy service.
For venous procedure, two new codes are available for 2006:
• 37187: initial treatment by mechanical thrombectomy
• 37188: for repeat treatment on a subsequent day during the course of thrombolytic therapy
These codes include intra-procedural pharmacological thrombolytic injections and fluoroscopy and to assign the code for repeat treatment appropriately, the coder must have access to longitudinal patient record documentation. It’s also helpful for the coder to review Appendix L in the CPT manual, which contains the Vascular Family information, essential for appropriate vascular CPT coding.
New code 44180 is now available for laparoscopic enterolysis (freeing of intestinal adhesions). Be aware that the code carries a “separate procedure” designation and that the physician documentation must support the use of this code. It must be either:
• The only procedure performed, or
• It must have involved major time or resources beyond a typical enterolysis procedure used as an approach.
New code 44186 is to be reported for laparoscopic jejunostomy procedures. Most commonly, the code will be used for decompression or feeding tubes. Note that there are also new codes 44187 (ileostomy or jejunostomy, non-tube) and 44188 (colostomy or skin-level cecostomy), but that these two codes are designated as “inpatient only” and should not be performed on Medicare patients on an outpatient basis.
When a mobilization or take-down procedure of the splenic flexure is performed laparoscopically in conjunction with a partial colectomy, new code 44213 should be reported. The code is considered an add-on code and should be assigned in addition to the code for the primary procedure. This code is typically used for patients with midrectal cancer or when there is too much tension on a colorectal anastomosis. The new code was developed because the service requires more work, placement of additional ports and is near the spleen, which increases the risk of injury and hemorrhage.
New code 45990 is reported for an anorectal examination that requires general, spinal or epidural anesthesia. This code includes the following services: external perineal exam, digital rectal exam, pelvic exam (when performed), diagnostic anoscopy and diagnostic rigid proctoscopy. The code is intended for those instances in which the examination is the only service performed; it is not to be reported separately when any other surgical anal procedure is performed during the same operative episode.
New code 46505 is now available for internal anal sphincter chemodenervation procedures. This service involves injection of botulinum toxin into the internal anal sphincter muscle tissue to allow loosening of the anal opening and accommodate healing of a fissure. The service is less invasive than typical open surgical techniques and may be provided in place of surgical procedure. Clinical visits are maintained during the “weakened” state of the muscle, which produces the equivalent of a surgical lateral internal sphincterotomy.
Urinary and Genital Systems
Four new codes were developed that describe ureteral stent removal, differentiated by approach (percutaneous and transurethral) and by type (internally indwelling and externally dwelling). Ureteral stents are typically used to treat ureteral strictures and obstructions; they must be monitored while in place and periodically replaced. The codes are as follows:
• 50382: reported for percutaneous approach for removal and replacement of an internally dwelling stent;
• 50384: reported for percutaneous approach for removal only of internally dwelling stent;
• 50387: reported for removal and replacement of externally accessible transnephric ureteral stent (including fluoroscopy);
• 50389: reported for removal of nephrostomy tube (including fluoroscopy).
Coders should be aware that exclusionary cross-references were included following codes 50387 and 50389, indicating that stent removals not requiring fluoroscopic guidance are considered to be inherent in the Evaluation and Management (E/M) service. For hospital coders, this means that no invasive CPT code should be reported for this service. In most cases, this type of service would not require the use of an operating room. The new stent removal codes are considered inherently unilateral; if the service is performed bilaterally, modifier 50 should be appended to the code.
Two new codes for laparoscopic approach to renal lesion ablation are now available, differentiated by type of lesion. Report 50541 for treatment of renal cysts and code 50542 for treatment of renal masses. New code 50592 is also a new code that was developed to represent extracorporeal shock wave lithotripsy (ESWL) of renal tumor(s). Coders should also be aware that Category III code 0135T should be reported if cryotherapy ablation is performed for these cases.
CPT 2006 also contains a significant revision to the prostatic hypertrophy treatment codes. Existing codes 52647 and 52648 have been editorially revised to eliminate the word “contact” to reflect current clinical practice. Over the past 10 years there have been ad-vances in laser fiber technology that allows tissue vaporization and cavitation without direct tissue contact. The two codes are now differentiated by technique, i.e., whether by coagulation or vaporization. In addition, similar code C9713, required for Medicare cases in the past, has been deleted.
Revisions were made to terminology of code 57421 to indicate that biopsies of only vaginal or cervical tissue is included in the code. A cross-reference was also added to direct the coder to code 58110 for endometrial sampling, when performed in conjunction with colposcopy. New code 58110 is designated as an add-on code, which should be assigned in addition to the code for the primary procedure. If only endocervical curettage is performed, report 57505.
CPT code 64613 (Chemodenervation of muscle(s) É) has been revised to avoid limiting the muscle groups that the code describes. While the chemodenervation service may be performed on cervical spinal muscles to treat spasmodic torticollis, it may also be performed to treat spasmodic dysphonie, which affects a different group of muscles in the neck region. The revised terminology now indicates only “neck muscles.”
Two new codes have been developed that reflect chemodenervation services for treatment of severe focal hyperhidrosis (excessive sweating). The new codes are as follows:
• 64650: reported for services involving both axillae;
• 64653: reported for services involving other areas (e.g., scalp, face, neck);
If these services are performed on extremities (e.g., hands or feet), assign unlisted code 64999.
Eye and Ocular Adnexa System
Current blepharoptosis repair codes 67901 and 67902 have been revised to reflect the current practice of using banked fascial strips vs. autologous fascial grafting. Assign code 67902 when the documentation indicates that the physician harvests the fascia with a fascial stripper from the same patient (autologous) who will be receiving the autogenous fascia to repair an eyelid defect (e.g., brow ptosis or blepharoptosis).
After reviewing the new 2006 CPT codes and guidelines, along with Appendix B (Summary of Additions, Deletions, and Revisions) in the CPT manual, take the following quiz to test your knowledge.
1. A 73-year-old patient with a chronic indwelling double-J stent, initially placed for ureteral obstruction, was seen after a failed attempt to exchange the stent cystoscopically. The stent was fractured and the distal portion is now inaccessible from a urethral approach so a transnephric approach was performed. A small skin incision was made after 1% lidocaine infiltration. With imaging guidance a needle was introduced into the appropriate renal calyx and fluoroscopy confirmed positioning. A guidewire and sheath were introduced into the renal pelvis, the needle removed and the tract was dilated. The snare device was negotiated into the renal pelvis and grasped the proximal end of the indwelling stent and the stent was pulled out through the sheath. The replacement stent was advanced over the wire until the distal loop was in the bladder. The distal loop was deployed, placement confirmed and the wire was withdrawn. The appropriate CPT code(s) is/are as follows:
2. A 47-year-old female has chronic plantar fasciitis and has failed 6 months of conservative therapy without resolution of symptoms. The point of maximal tenderness was identified and marked on the patient’s heel, after which coupling gel was applied to the heel and the shock wave generating device was positioned appropriately. High energy shock waves are then administered according to standard protocol until the appropriate energy level is achieved. The appropriate CPT code(s) is/are as follows:
3. A 77-year-old patient presents with rest pain of the right lower extremity and work-up shows a focal high-grade stenosis of the distal superficial femoral artery (SFA). The patient is referred for a PTA and/or stent placement. Percutaneous transluminal angioplasty is performed with a balloon, but follow-up angiography shows patency of the PTA site. However, a stagnant column of contrast with no run-off and distal imaging shows a filling defect at the popliteal artery bifurcation. The existing sheath is upsized to allow placement of a larger-bore catheter. Over a wire, a guiding catheter is advanced into the popliteal artery distally at the level of the embolus. A 30 cc syringe is attached to the catheter, placing suction to the embolus. With suction continuously applied, the guiding catheter is removed from the sheath, pulling the embolus from the vessel. Follow-up angiography is done, demonstrating complete removal of the embolus. The appropriate surgical CPT code(s) is/are as follows:
b. 35474, 37186
c. 35476, 37186
This month’s column has been prepared by Cheryl D’Amato, RHIT, CCS, director of HIM, and Melinda Stegman, MBA, CCS, manager of clinical HIM services, HSS, an Ingenix Company. (www.hssweb.com), which specializes in the development and use of software and e-commerce solutions for managing coding, reimbursement, compliance and denial management in the health care marketplace.
Coding Clinic is published quarterly by the American Hospital Association.
CPT is a registered trademark of the American Medical Association.
Answers to CCS PREP!: 1. d. The ureteral stent was replaced via a percutaneous approach. The other codes are inappropriate because they represent services that are either removal only, open incisional approach or incision into the bladder itself; 2. c. New code 28890 was specifically developed for treatment of plantar fasciitis using high energy extracorporeal shock wave therapy. The other codes are inappropriate because they represent either low-energy treatment, different non-specific body sites or sites not including the elbow or plantar fascia; 3. b. The procedure involved a “rescue arterial thrombectomy,” which is considered a secondary arterial thrombectomy procedure and the add-on code 37186 is reported in addition to the primary popliteal PTA procedure (35474).