ICD-9-CM and CPT coding update
By Therese M. Jorwic, MPH, RHIA, CCS, CCS-P
Musculoskeletal system
The new surgery codes begin with the musculoskeletal system.
New code 22586 is for arthrodesis, or fixation of a joint, in this case the spine. It covers the pre-sacral area, which is the L5 to S1 section of the sacrum right above the tailbone, with the interbody technique.
This code gets used whether the procedure is done alone or with another procedure, and it includes the entire process – preparation of the disc space, disc removal, fixation, grafting, and whatever image guidance is necessary.
Also new here are four codes for the revision of an arthroplasty, or joint replacement. A redo can become necessary, for example, when the original prosthesis wears out. The codes include the removal of the old prosthesis and the placement of a new one.
The first two codes (23473 and 23474) apply to total shoulder replacements, with 23473 for replacement of either the humeral or glenoid component and 23474 for replacement of both components.
The other two (24370 and 24371) apply in the same way to total elbow replacements, with 24370 applying to either the humeral or ulnar portion and 24371 to both.
Respiratory system
There are 11 new codes here. The first four (31647-31649 and 31651) are for bronchoscopies, both rigid and flexible, with balloon occlusions, and they include moderate sedation and guidance. These codes replace three Category III codes, which are temporary codes for new technologies (0250T, 0251T, and 0252T).
Code 31647 is for the insertion of one or more bronchial valves into the initial lobe, and 31648 is for the removal of one or more, again from the initial lobe. Code 31649 is an add-on for valve removal from each additional lobe, and 31651 is an add-on for valve insertion into each additional lobe.
Following those are newcomers 31660 and 31661 for bronchoscopy with bronchial thermoplasty, a procedure usually used to treat severe and persistent asthma. A catheter delivers thermal energy to the smooth muscles of the airways, which limits their ability to constrict air flow. The procedure, which does not destroy the tissue, reduces flare-ups and prevents a lot of visits to the emergency room.
Those two codes replace 0276T and 0277T.
Next are four new codes for thoracentesis and pleural drainage (32554-32557), which is the removal of fluid or air from the pleural space.
The first two are for removal via needle aspiration (without and with image guidance), and the others are for draining via an indwelling catheter (without and with image guidance).
The final new respiratory code is 32701. It appears in a new subhead for stereotactic radiation therapy, and it is for identifying the size and location of a thoracic tumor for radiation therapy.
Stereotactic therapy is noninvasive and allows for precise delivery of small doses of radiation over several days.
Cardiovascular system
TAVRs: There are a number of new codes and guideline changes here.
First are new codes for transcatheter aortic valve replacement, or TAVR (33361-33365 and 33367-33369).
TAVR is a minimally invasive procedure to replace the aortic valve, and it is used for patients with stenosis, or narrowing of the valve. The term is used synonymously with TAVI, or transcatheter aortic valve implementation.
Again, these are Category III codes that have graduated to full CPT status. They replace 0256T, 0258T, and 0259T. (Code 0257T has been deleted, and new code 0318T has been added for TAVR with a transapical approach.)
The procedure requires two physicians, so modifier 62 (two physicians working together) is always used with these codes. A lot of elements are included such as the temporary insertion of a pacemaker, radiological interpretation, contrast injections, and so on.
Specifically, the TAVR codes are
33361 – percutaneous femoral artery approach
33362 – open femoral artery approach
33363 – open axillary or armpit artery approach
33364 – open iliac or pelvic artery approach
33365 – transaortic approach, or via the aorta
There is also a new Category III code that goes with these. It is 0318T, which shows the implantation of an aortic valve via the chest.
The other three codes (33367-33369) are add-ons to show cardiopulmonary bypass support.
pVADs: Next come 33990-33993 for the insertion, removal, and repositioning of a percutaneous ventricular assist device, or pVAD. All are percutaneous procedures, not open, and they include moderate sedation.
A pVAD helps the ventricles of the heart contract. It can be used short-term for surgery patients who have restricted ventricle function. It can also be used to stabilize patients who are critically ill.
Angiography: After that are eight new codes (36221-36228) for diagnostic angiography, or imaging of the carotid artery.
Code 36221 is for nonselective placement, which means the catheter is inserted directly in the artery or vein and does not extend into a branch. The others are for selective placement, which means the catheter is moved beyond the vessel into a vascular family.
The codes identify the individual areas of the artery that are imaged.
Two of them are add-ons: 36227 (for 36222, 36223, or 36224) and 36228 (for 36224 or 36226).
Transcatheter procedures: The other new cardiovascular codes are for transcatheter procedures.
Code 37197 is for percutaneous retrieval of a blood clot. The others are for transcatheter infusion to break up a clot. They cover starting the infusion (37211 for arterial and 37212 for venous), subsequent days of infusion (37213), and stopping the therapy, removing the catheter, and closing the vessel (37214). They all include the radiologic supervision and interpretation as well as moderate sedation.
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A new CPT change to note: ‘other qualified providers’ HIPAA has two main parts. One is the Privacy Rule, which requires that offices take steps to ensure their patients’ protected health information is kept confidential. The other is the Security Rule. It carries the confidentiality concept further and tells what offices have to do to ensure that their electronic data is not lost or corrupted or accessed inappropriately. The Security Rule lays out standards that offices have to meet. Some are required and some are addressable. But addressable doesn’t mean the standard can be skipped or ignored. It only means that if the standard doesn’t apply to the office or if the office is taking other steps to achieve the same result, it doesn’t have to be met exactly. And when that’s the case, the office has to document why it’s taking some other route. Encryption is an example. It’s an addressable standard. The office is not required to encrypt its data, but if it doesn’t, it has to explain why, perhaps that it doesn’t e-mail information. The required standards, on the other hand, have to be met exactly. And a Risk Analysis is one of them. Everybody has to have an analysis. |
Hemic and lymphatic systems
For the hemic and lymphatic systems, there is just one new addition, and it is 38243 for HPC boost.
HPC, or hematopoietic progenitor cells, are obtained from bone marrow and also from blood, including umbilical cord blood. They are transplanted into patients with cancers of the blood or bone marrow, including leukemia.
The HPC boost is used for bone marrow transplant patients who are experiencing a deficiency in white blood cells. The boost gives them additional cells.
Digestive system
In this section are three new codes.
The first is for esophagoscopy with optical endomicroscopy (43206), and the second is for upper GI endoscopy with optical endomicroscopy (43252).
Endomicroscopy is microscopic imaging, or real time visualization of the mucosal tissues to identify the precise sites were biopsies need to be taken.
Third is 44705 for the preparation of fecal microbiota used to treat an imbalance of bacteria in the digestive system. It is often used for patients with severe clostridium difficile, or C. diff that does not respond to standard treatment.
The sample is taken from a healthy donor, usually a relative, and is introduced to encourage the growth of beneficial bacteria.
Urinary system
The urinary system has just one new addition, which is 52287 for cystourethroscopy injections for chemodenervation of the smooth muscles of the bladder. The injections treat the incontinence that occurs when those muscles become too active.
Nervous system
The last new surgery code is also for chemodernation. It is 64615, and it is for destruction of facial, trigeminal, cervical spinal, and accessory nerves in patients with chronic migraines.
To qualify for this procedure, the patient must meet the criteria for chronic migraines, which is three consecutive months of headaches occurring on at least 15 days, each headache lasting at least four hours.
Therese M. Jorwic, MPH, RHIA, CCS, CCS-P, is assistant professor of health information management at the University of Illinois at Chicago and senior consultant for MC Strategies in Atlanta.
