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All rights reserved. Fee schedules, relative value units,
conversion factors and/or related components are not assigned by
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Slide 3
Highlights for Hospitals, Physicians and Health Plans 2014 OIG
Work Plan
Slide 4
2015 OIG Work Plan O The HHS Office of Inspector General (OIG)
Work Plan for Fiscal Year 2015 summarizes new and ongoing reviews
and activities that OIG plans to pursue with respect to HHS
programs and operations during the current fiscal year and beyond.
O The Work Plan describes the primary objectives and provides for
each review its internal identification code and the year in which
we expect one or more reports to be issued as a result of the
review. O When reports are issued, they are posted to OIG's
website. OIG's email list subscribers automatically receive
notification when new reports are posted to the website.
Slide 5
2015 OIG Work Plan O New Inpatient Admission Criteria O We will
determine the impact of new inpatient admission criteria on
hospital billing, Medicare payments, and beneficiary copayments. O
Previous OIG work identified millions of dollars in overpayments to
hospitals for short inpatient stays that should have been billed as
outpatient stays. O Beginning in FY 2014, new criteria state that
physicians should admit for inpatient care those beneficiaries who
are expected to need at least 2 nights of hospital care (known as
the two midnight policy). O Beneficiaries whose care is expected to
last fewer than 2 nights should be treated as outpatients. The
criteria represent a substantial change in the way hospitals bill
for inpatient and outpatient stays.
Slide 6
2015 OIG Work Plan O Medicare Costs Associated with Defective
Medical Devices O We will review Medicare claims to identify the
costs resulting from additional use of medical services associated
with defective medical devices and determine the impact of the cost
on the Medicare Trust Fund. O CMS has previously expressed concerns
about the impact of the cost of replacement devices, including
ancillary cost, on Medicare payments for inpatient and outpatient
services.
Slide 7
2015 OIG Work Plan O Medicare Oversight of Provider-based
Status O We will determine the extent to which provider- based
facilities meet CMSs criteria. O Provider-based status allows
facilities owned and operated by hospitals to bill as hospital
outpatient departments. (POS 15 vs 22) O Provider-based status can
result in higher Medicare payments for services furnished at
provider-based facilities and may increase beneficiaries
coinsurance liabilities.
Slide 8
2015 OIG Work Plan O Comparison of Provider-based and
Free-standing Clinics O We will review and compare Medicare
payments for physician office visits in provider-based clinics and
free-standing clinics to determine the difference in payments made
to the clinics for similar procedures and assess the potential
impact on the Medicare program of hospitals' claiming provider
based status for such facilities. O Provider-based facilities often
receive higher payments for some services than do freestanding
clinics.
Slide 9
2015 OIG Work Plan O Inpatient Claims for Mechanical
Ventilation O We will review Medicare payments for inpatient
hospital claims with certain MS-DRG assignments that require
mechanical ventilation to determine whether hospitals DRG
assignments and resultant Medicare payments were appropriate. O
Mechanical ventilation is the use of a ventilator or respirator to
take over active breathing for a patient. Claims must be completed
accurately to be processed correctly and promptly. O For certain
DRGs to qualify for Medicare coverage, a patient must receive 96 or
more hours of mechanical ventilation. Our review will include
claims for beneficiaries who received over 96 hours of mechanical
ventilation. Previous OIG reviews identified improper payments made
because hospitals inappropriately billed for beneficiaries who did
not receive 96 or more hours of mechanical ventilation.
Slide 10
2015 OIG Work Plan O Outpatient E/M Services Billed at the
New-patient Rate (G0463) O We will review Medicare outpatient
payments made to hospitals for evaluation and management (E/M)
services for clinic visits billed at the new-patient rate to
determine whether they were appropriate and will recommend recovery
of overpayments. O Preliminary work identified overpayments that
occurred because hospitals used new-patient codes when billing for
services to established patients. O The rate at which Medicare pays
for E/M services requires hospitals to identify patients as either
new or established, depending on previous encounters with the
hospital. O According to Federal regulations, the meaning of new
and established pertains to whether the patient has been seen as a
registered inpatient or outpatient of the hospital within the past
3 years.
Slide 11
2015 OIG Work Plan O Nationwide Review of Cardiac Caths and
Endomyocardial Biopsies O We will review Medicare payments for
right heart catheterizations (RHC) and endomyocardial biopsies
billed during the same operative session and determine whether
hospitals complied with Medicare billing requirements. O Previous
OIG reviews have identified inappropriate payments when hospitals
were paid for separate RHC procedures when the services were
already included in payments for endomyocardial biopsies. To be
processed correctly and promptly, a bill must be completed
accurately.
Slide 12
2015 OIG Work Plan O Risk adjustment dataSufficiency of
documentation supporting diagnoses O We will review the medical
record documentation to ensure that it supports the diagnoses MA
organizations submitted to CMS for use in CMSs risk-score
calculations and determine whether the diagnoses submitted complied
with Federal requirements. O Prior OIG reviews have shown that
medical record documentation does not always support the diagnoses
submitted to CMS by MA organizations. O MA organizations are
required to submit risk adjustment data to CMS in accordance with
CMS instructions. O Payments to MA organizations are adjusted on
the basis of the health status of each beneficiary, so inaccurate
diagnoses may cause CMS to pay MA organizations improper
amounts.
Slide 13
2013 OIG Posted Audit Results Results have been posted to the
OIG website for six Medicare Advantage Organizations General
Findings: O The MAO did not have written policies and procedures
for obtaining, processing, and submitting diagnoses to CMS. O
Practices were not effective in ensuring that the diagnoses MAO
submitted to CMS complied with the requirements of the Risk
Adjustment Participant Guide.
Slide 14
2013 OIG Posted Audit Results Results have been posted to the
OIG website for 6 Medicare Advantage Organizations Coding/Claims
specific issues O Documentation did not support the claimed
diagnosis. O Documentation did not include the providers signature
or credentials. O No documentation was offered to support
diagnosis. O Unconfirmed diagnoses
Slide 15
2013 OIG Posted Audit Results Results have been posted to the
OIG website for 6 Medicare Advantage Organizations Coding/Claims
specific issues O No documentation that diagnosis affected the
care, treatment, or management provided during the encounter. O
Taking diagnosis codes from problem lists or other documentation
that merely lists diagnoses with no indication of evaluation and
treatment for each condition. O Taking diagnoses from patient
histories or history codes. O Claiming a diagnosis code based
solely on prescription medication.
Slide 16
2013 OIG Posted Audit Results O Audit Scrutiny of Medicare Risk
Adjustment Payments- (extrapolated) O PacifiCare of Texas-
$115,422,084 (43% not validated) O
http://oig.hhs.gov/oas/reports/region6/60900012.pdf
http://oig.hhs.gov/oas/reports/region6/60900012.pdf O Excellus
Health Plan- $41,588,811 (46% coding not validated) O
https://oig.hhs.gov/oas/reports/region2/20901014.pdf
https://oig.hhs.gov/oas/reports/region2/20901014.pdf O Pacific Care
of California- $423,709,068- (45% not validated) O
https://oig.hhs.gov/oas/reports/region9/90900045.pdf
https://oig.hhs.gov/oas/reports/region9/90900045.pdf
Slide 17
2013 OIG Posted Audit Results O Audit Scrutiny of Medicare Risk
Adjustment Payments- (extrapolated) O Paramount Care (Promedica)-
$18,216,541 (44% not validated) O
https://oig.hhs.gov/oas/reports/region5/50900044.pdf
https://oig.hhs.gov/oas/reports/region5/50900044.pdf O Bravo Health
Pennsylvania- $22,108,905 (65% not validated) O
https://oig.hhs.gov/oas/reports/region3/30900003.pdf
https://oig.hhs.gov/oas/reports/region3/30900003.pdf O Cigna
Healthcare of Arizona- $28,353,516 (40% not validated) O
https://oig.hhs.gov/oas/reports/region7/71001082.pdf
https://oig.hhs.gov/oas/reports/region7/71001082.pdf
Slide 18
Modifiers, G codes, Anesthesia, Global Surgery Concepts 2015
OPPS Update
Slide 19
CMS- Modifier 59 O Previous OIG Report on Modifier 59 O On
August 15, 2014 CMS released the final ruling for appropriate
Modifier 59 use. (Transmittal 1422, CR8863) O The changes will take
effect on January 1, 2015. O These modifiers, are referred to as
X-EPSU modifiers, and define specific subsets of the -59 modifier.
O CMS will not stop recognizing the -59 modifier but notes that CPT
instructions state that the -59 modifier should not be used when a
more descriptive modifier is available..
Slide 20
CMS- Modifier 59 O Transmittal 1422, CR8863 details new
modifiers to be used in place of modifier 59. The new modifiers
will impact NCCI (National Correct Coding Initiative) edits
utilized by CMS MAC Carriers. O XE Separate Encounter: Service That
Is Distinct Because It Occurred During A Separate Encounter O XP
Separate Practitioner: Service That Is Distinct Because It Was
Performed By A Different Practitioner O XS Separate Structure:
Service That Is Distinct Because It Was Performed On A Separate
Organ/Structure O XU Unusual Non-Overlapping Svc: Use Of A Service
That Is Distinct Because It Does Not Overlap usual components of
the main service
Slide 21
CMS- Modifier 59 O The new modifiers are to be used in place of
modifier 59. They will impact NCCI (National Correct Coding
Initiative) edits utilized by CMS MAC Carriers. O Studies have
shown that the modifier 59 is both commonly used and commonly
abused. O According to the 2013 CERT report $2.4 billion was paid
on claims containing modifier 59 with a projected error rate of
$450 million. O The error rate is not exclusively attributed to
modifier 59, but if only 10% of those found to be in error were due
to the modifier 59, that would represent a $45 million damage. O No
word on recognition of these modifiers by other payers.
Slide 22
CMS- Updates O G codes for new CPT codes- If the new CPT codes
are unavailable at the time the OPPS final rule is published, CMS
will be issuing G codes for these services and they will be valued
accordingly. O The 2015 rates of the created G codes will be based
on the comparable 2014 CPT codes.
Slide 23
CMS- Updates O Anesthesia for Screening Colonoscopies- in the
past moderate sedation was included in endoscopy services. O
Anesthesia is now being used more frequently with these services. O
For 2015, all anesthesia will be included in screening colonoscopy
codes. O This will result in coinsurance and deductible being
waived for the patient. O Anesthesiologist should bill with -33 to
show it is for screening service.
Slide 24
CMS- Updates O Global Surgery- Transforming all 10 day and 90
day global periods into 0 day global periods. Goal is: O 10 day in
CY 2017 O 90 day in CY 2018 O Goal is to value all services
appropriately taking into consideration each component,
pre-operative, intra-operative and post- operative components.
Slide 25
2015 CPT Changes All Rights Reserved 2012
Slide 26
2015 CPT Changes O 542 Total Code Changes O 266 New Codes O 147
Deleted Codes O 129 Revised Codes O Guideline Changes
Slide 27
Evaluation and Management 99000-99499
Slide 28
Evaluation and Management O Evaluation and Management Workgroup
O Created in response from AMA members regarding increased use of
templates and EMRs creating over documentation and inflation of E/M
services. O Define the importance of making MDM a required key
component in determining E/M code O Determined to be a more
substantial change than anticipated. O Unable to be implemented at
this time, assigning appropriate values O Work tabled for use in
the future.
Slide 29
Evaluation and Management O Social History- The social history
element of history documentation in the E/M guidelines has been
revised to include any history of military service. The addition of
this element will assist with diagnosing, assessing, and treating
service members, veterans and their families.
Slide 30
Evaluation and Management O Deleted 99481- Total body systemic
hypothermia in a critically ill neonate per day O Deleted 99482-
Selective head hypothermia in a critically ill neonate per day O
New Code (in the medicine section) 99184- Initiation of selective
head or total body hypothermia in the critically ill neonate,
includes appropriate patient selection by review of clinical,
imaging and laboratory data, confirmation of esophageal temperature
probe location, evaluation of amplitude EEG, supervision of
controlled hypothermia, and assessment of patient tolerance of
cooling
Slide 31
Evaluation and Management O Care Management Services-
Guidelines clarified O Chronic Care Management Services O Complex
Chronic Care Management Services O Transitional Care Management
Services O Advanced Care Planning
Slide 32
Evaluation and Management O Chronic Care Management Services
(Revised Code)- O 99490- Chronic care management services, at least
20 minutes of clinical staff time directed by a physician or other
qualified health care professional, per calendar month, with the
following required elements: multiple (two or more) chronic
conditions expected to last at least 12 months, or until the death
of the patient; chronic conditions place the patient at significant
risk of death, acute exacerbation/decompensation, or functional
decline; comprehensive care plan established, implemented, revised,
or monitored O CCMS of less than 20 minutes duration are not
reported separately.
Slide 33
Evaluation and Management O Maternity Care and Delivery
Guidelines Clarifications O The services normally provided in
uncomplicated maternity cases include antepartum care, delivery and
postpartum care. Pregnancy confirmation during a problem oriented
or preventive visit is not considered a part of antepartum care and
should be reported using the appropriate E/M service code for that
visit.
Slide 34
Anesthesia 00100-01999
Slide 35
Anesthesia O Codes deleted due to low utilization: O 00452-
Anesthesia for procedures on clavicle and scapula; radical surgery
O 00622- Anesthesia for procedures on thoracic cord and spine;
thoracolumbar sympathectomy O 00634- Anesthesia for procedures in
lumbar region; lumbar sympathectomy
Slide 36
General Surgery Surgery Guidelines 10021-10022
Slide 37
General Surgery O CPT Surgical Package Definition- By their
very nature, the services to any patient are variable. The CPT
codes that represent a readily identifiable surgical procedure
thereby include, a variety of services. The following services
related to the surgery when furnished by the physician or other
qualified health care professional who performs the surgery are
included: O E/M services subsequent to the decision for surgery on
the day before and/or day of surgery (including H&P) O Local
infiltration, digital block or topical anesthesia O Immediate PO
care including dictation of operative note, talking with family and
other physicians O Writing orders O Evaluating the patient in the
recovery area O Typical postoperative follow up care O Addresses
inclusive E/M services, clarifies who can perform services,
clarifies what services are included.
Slide 38
Integumentary 10030-19499 No Changes for 2015!!
Slide 39
Musculoskeletal 20005-29999
Slide 40
Musculoskeletal O Joint Procedures O The existing code series
was updated to indicate with/without Ultrasound guidance O 20600-
Arthrocentesis, aspiration and/or injection; small joint or bursa
(eg, fingers, toes); without ultrasound guidance O 20604-
Arthrocentesis, aspiration and/or injection, small joint or bursa
(eg, fingers, toes); with ultrasound guidance, with permanent
recording and reporting O 20605- Arthrocentesis, aspiration and/or
injection, intermediate joint or bursa (eg, temporomandibular,
acromioclavicular, wrist, elbow or ankle, olecranon bursa); without
ultrasound guidance O 20606 Arthrocentesis, aspiration and/or
injection, intermediate joint or bursa (eg, temporomandibular,
acromioclavicular, wrist, elbow or ankle, olecranon bursa); with
ultrasound guidance, with permanent recording and reporting
Slide 41
Musculoskeletal O Joint Procedures O 20610- Arthrocentesis,
aspiration and/or injection, major joint or bursa (eg, shoulder,
hip, knee, subacromial bursa); without ultrasound guidance O 20611
Arthrocentesis, aspiration and/or injection, major joint or bursa
(eg, shoulder, hip, knee, subacromial bursa); with ultrasound
guidance, with permanent recording and reporting O Parenthetical
notes restricts use of 76942 with these codes. O If Flouroscopic,
MRI or CT guidance used, report codes 20600, 20605 or 20610 for the
procedure, and then code guidance 77002, 77012, 77021.
Slide 42
Musculoskeletal O Ablation Therapy O The existing code for
radiofrequency bone ablation has been updated to include adjacent
soft tissue and radiologic guidance. In addition, a new code has
been added for cryoablation of bone tumors. O 20982- Ablation
therapy for reduction or eradication of 1 or more bone tumors (eg,
metastasis), including adjacent soft tissue when involved by tumor
extension, percutaneous, including imaging guidance when performed;
radiofrequency O 20983- cryoablation
Slide 43
Musculoskeletal O Vertebroplasty/Kyphoplasty O The existing
codes have been deleted and new codes have been created to include
all imaging guidance. It was found imaging guidance was used 75% of
the time. O 22510 - Percutaneous vertebroplasty (bone biopsy
included when performed), 1 vertebral body, unilateral or bilateral
injection, inclusive of all imaging guidance; cervicothoracic O
22511- lumbosacral O +22512- each additional cervicothoracic or
lumbosacral vertebral body (List separately in addition to code for
primary procedure)
Slide 44
Musculoskeletal O Vertebroplasty/Kyphoplasty- cont O 22513-
Percutaneous vertebral augmentation, including cavity creation
(fracture reduction and bone biopsy included when performed) using
mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral
or bilateral cannulation, inclusive of all imaging guidance;
thoracic O 22514- lumbar O +22515- each additional thoracic or
lumbar vertebral body (List separately in addition to code for
primary procedure) O Current codes 22520, 22521, 22522, 22523,
22524, 22525, 72291 and 72292 have been deleted
Slide 45
Musculoskeletal Vertebroplasty Kyphoplasty
Slide 46
Musculoskeletal O Sacroplasty O Sacroplasty did not yet receive
a new code, but the existing Category III code has been revised to
include all imaging guidance. O 0200T Percutaneous sacral
augmentation (sacroplasty), unilateral injection(s), including the
use of a balloon or mechanical device, when used, 1 or more
needles, includes imaging guidance and bone biopsy, when performed
O 0201T Percutaneous sacral augmentation (sacroplasty), unilateral
injection(s), including the use of a balloon or mechanical device,
when used, 2 or more needles, includes imaging guidance and bone
biopsy, when performed
Slide 47
Musculoskeletal O Open Treatment of Rib Fractures O 21800,
21810, 0245T, 0246T, 0247T, 0248T have been deleted O 21811- Open
treatment of rib fracture(s) with internal fixation, includes
thoracoscopic visualization when performed, unilateral; 1-3 ribs O
21812- 4-6 ribs O 21813- 7 or more ribs O Codes selected based on
the number of ribs treated
Slide 48
Musculoskeletal O Total Disc Arthroplasty O 22856 Revised to be
the parent code for 22858 O 22856- Total disc arthroplasty
(artificial disc), anterior approach, including discectomy with end
plate preparation (includes osteophytectomy for nerve root or
spinal cord decompression and microdissection), single interspace,
cervical O 22858- second level, cervical (List separately in
addition to code for primary procedure) O 0375T- cervical, three or
more levels
Slide 49
Musculoskeletal
Slide 50
O Arthrodesis of Sacroiliac Joint O 27279- Arthrodesis,
sacroiliac joint, percutaneous or minimally invasive (indirect
visualization), with image guidance, includes obtaining bone graft
when performed, and placement of transfixing device O 27280-
Arthrodesis, sacroiliac joint (including obtaining graft), open O
Codes are unilateral, use -50 if bilateral
Slide 51
Respiratory 30000-32999
Slide 52
Respiratory O Ablation Pulmonary Tumors O A Category III code
has been created for cryoablation of pulmonary tumors. O 0340T-
Ablation, pulmonary tumor(s), including pleura or chest wall when
involved by tumor extension, percutaneous, cryoablation,
unilateral, includes imaging guidance
Slide 53
Respiratory
Slide 54
Cardiovascular 33010-36556
Slide 55
Cardiovascular O Subcutaneous Pacemaker or Implantable
Defibrillator O Category III codes 0319T, 0320T, 0321T, 0322T,
0323T, 0324T, 0326T, 0327T have been deleted and replaced with
Category I codes. O Revisions have been made to the established
codes, guidelines and the table has been updated with the new
codes
Slide 56
Cardiovascular O Subcutaneous Pacemaker or Implantable
Defibrillator O 33270- Insertion or replacement of permanent
subcutaneous implantable defibrillator system, with subcutaneous
electrode, including defibrillation threshold evaluation, induction
of arrhythmia, evaluation of sensing for arrhythmia termination,
and programming or reprogramming of sensing or therapeutic
parameters, when performed
Slide 57
Cardiovascular O Subcutaneous Pacemaker or Implantable
Defibrillator O 33271- Insertion of subcutaneous implantable
defibrillator electrode O 33272- Removal of subcutaneous
implantable defibrillator electrode O 33273- Repositioning of
previously implanted subcutaneous implantable defibrillator
electrode
Slide 58
Cardiovascular O Transcatheter Mitral Valve Repair O Category
III codes 0343T and 0344T have been deleted and replaced with
Category I codes. O 33418- Transcatheter mitral valve repair,
percutaneous approach, including transseptal puncture when
performed; initial prosthesis O 33419- additional prosthesis(es)
during same session (List separately in addition to code for
primary procedure) O 0345T- Transcatheter mitral valve repair
percutaneous approach via the coronary sinus
Slide 59
Cardiovascular
Slide 60
O Extracorporeal Membrane Oxygenation (ECMO) O 33960, 33961,
36822 have been deleted O New category and guidelines created O New
codes include: Initiation of ECMO, daily management, cannulation,
repositioning, adding, removing of cannula
Slide 61
Cardiovascular
Slide 62
O Extracorporeal Membrane Oxygenation (ECMO) O 33946-
Extracorporeal membrane oxygenation (ECMO)/extracorporeal life
support (ECLS) provided by physician; initiation, veno-venous O
33947- initiation, veno-arterial O 33948- daily management, each
day, veno-venous O 33949- daily management, each day,
veno-arterial
Slide 63
Cardiovascular O Extracorporeal Membrane Oxygenation (ECMO) O
33951- Extracorporeal membrane oxygenation (ECMO)/extracorporeal
life support (ECLS) provided by physician; insertion of peripheral
(arterial and/or venous) cannula(e), percutaneous, birth through 5
years of age (includes fluoroscopic guidance, when performed) O
33952- 6 years or older O 33953- open, birth-5 years O 33954- open,
6 years or older
Slide 64
Cardiovascular O Extracorporeal Membrane Oxygenation (ECMO) O
33955- insertion of central cannula(e) by sternotomy or
thoracotomy, birth through 5 years of age O 33956- 6 years or older
O 99357- reposition peripheral (arterial and/or venous) cannula(e),
percutaneous, birth through 5 years of age (includes fluoroscopic
guidance, when performed) O 33958- 6 years or older
Slide 65
Cardiovascular O Extracorporeal Membrane Oxygenation (ECMO) O
33959- reposition peripheral (arterial and/or venous) cannula(e),
open, birth through 5 years of age (includes fluoroscopic guidance,
when performed) O 33962- 6 years or older O 33963- by sternotomy or
thoracotomy, birth through 5 years of age O 33964- 6 years or
older
Slide 66
Cardiovascular O Extracorporeal Membrane Oxygenation (ECMO) O
33965- removal peripheral (arterial and/or venous) cannula(e),
percutaneous, birth through 5 years of age (includes fluoroscopic
guidance, when performed) O 33966- 6 years or older O 33969- open,
birth-5 years of age O 33984- open, 6 years or older
Slide 67
Cardiovascular O Extracorporeal Membrane Oxygenation (ECMO) O
33985- removal peripheral (arterial and/or venous) cannula(e), by
sternotomy or thoracotomy, birth through 5 years of age (includes
fluoroscopic guidance, when performed) O 33986- 6 years or
older
Slide 68
Cardiovascular O Transcatheter Placement of Intravascular
Stents O A multispecialty society request was made to establish a
new code to report the transcatheter placement of an intrathoracic
carotid vascular stent. O Editorial revision of cervical carotid
artery stent codes 37215-37216 and codes 0075T-0076T also was
requested to differentiate these codes from the new code and to
make them consistent with all other endovascular bundled
coding.
Slide 69
Cardiovascular O Transcatheter Placement of Intravascular
Stents O Existing codes for carotid stent placement have been
revised to include angioplasty and radiologic supervision and
interpretation. These codes should also be used for open or
percutaneous approach, which is a change for 2015. O 37215 -
Transcatheter placement of intravascular stent(s), cervical carotid
artery, open or percutaneous, including angioplasty, when
performed, and radiological supervision and interpretation; with
distal embolic protection O 37216- without distal embolic
protection
Slide 70
Cardiovascular O Transcatheter Placement of Intravascular
Stents O 37217- Transcatheter placement of an intravascular
stent(s), intrathoracic common carotid artery or innominate artery
by retrograde treatment, via open ipsilateral cervical carotid
artery exposure, including angioplasty, when performed, and
radiological supervision and interpretation
Slide 71
Cardiovascular O Transcatheter Placement of Intravascular
Stents O Previously a Category III code, there is now a CPT code
for placement of intrathoracic common carotid or innominate artery
stent. This code includes angioplasty and imaging. O 37218
Transcatheter placement of intravascular stent(s), intrathoracic
common carotid artery or innominate artery, open or percutaneous
antegrade approach, including angioplasty, when performed, and
radiological supervision and interpretation
Slide 72
Cardiovascular O Transcatheter Placement of Intravascular
Stents O 0075T- Transcatheter placement of extracranial vertebral
or intrathoracic carotid artery stent(s), including radiologic
supervision and interpretation, percutaneous; initial vessel O
0076T- each additional vessel
Slide 73
Digestive 40490-49999
Slide 74
Digestive O Esophagoscopy O 1 new code, 6 revised codes O
43180- Esophagoscopy, rigid, transoral with diverticulectomy of
hypopharynx or cervical esophagus (eg, Zenker's diverticulum), with
cricopharyngeal myotomy, includes use of telescope or operating
microscope and repair, when performed O 43194- Esophagoscopy,
rigid, transoral; with removal of foreign body O 43197-
Esophagoscopy, flexible, transnasal; diagnostic, includes
collection of specimen(s) by brushing or washing when performed
(separate procedure)
Slide 75
Digestive O Esophagoscopy O 43215- Esophagoscopy, flexible,
transoral; with removal of foreign body O 43216- with removal of
tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or
bipolar cautery O 43217- with removal of tumor(s), polyp(s), or
other lesion(s) by snare technique O 43250- with removal of
tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or
bipolar cautery O 43350 was deleted
Slide 76
Digestive O Endoscopy O Parent codes 44360, 44376, 44380,
44385, 44388, 45330 and 45378 are now designated as separate
procedures. O Editorial change to: including collection of
specimens by brushing or washing, when performed replaces with or
without collection of specimens for consistency with other codes. O
Control of bleeding instruction: Control of bleeding that occurs as
a result of the endoscopic procedure is not separately reportable
during the same operative session O Further Clarification of
modifiers 52 and 53
Slide 77
Digestive O Endoscopy, Small Intestine O Divided into two
separate subcategories: Endoscopy, Small Intestine and Endoscopy,
Stomal O New Section Guidelines have been added O 44360- Small
intestinal endoscopy, enteroscopy beyond second portion of
duodenum, not including ileum; diagnostic, with or without
collection of specimen(s) by brushing or washing (separate
procedure) O 44363- with removal of foreign body
Slide 78
Digestive O Endoscopy, Stomal O 44380- Ileoscopy, through
stoma; diagnostic, with or without collection of specimen(s) by
brushing or washing (separate procedure) O 44381- with
transendoscopic balloon dilation O 44382- with biopsy, single or
multiple O 44383 deleted O 44384- with placement of endoscopic
stent (includes pre- and post-dilation and guide wire passage, when
performed)
Slide 79
Digestive O Endoscopy, Stomal O 44385- Endoscopic evaluation of
small intestinal (abdominal or pelvic) pouch; diagnostic, with or
without collection of specimen(s) by brushing or washing (separate
procedure) O 44386- with biopsy, single or multiple
Slide 80
Digestive
Slide 81
O Endoscopy Stomal (Colon)- revised O 44388- Colonoscopy
through stoma; diagnostic, with or without collection of
specimen(s) by brushing or washing (separate procedure) O 44390-
with removal of foreign body O 44391- with control of bleeding, any
method O 44392- with removal of tumors, polyps or other lesions by
hot biopsy forceps
Slide 82
Digestive O Endoscopy Stomal (Colon)- new O 44401- Colonoscopy
through stoma; with ablation of tumor(s), polyp(s), or other
lesion(s) (includes pre-and post-dilation and guide wire passage,
when performed) O 44402- with endoscopic stent placement (including
pre- and post-dilation and guide wire passage, when performed) O
44403- with endoscopic mucosal resection O 44404- with directed
submucosal injection(s), any substance
Slide 83
Digestive O Endoscopy Stomal (Colon)- new O 44405- Colonoscopy
through stoma; with transendoscopic balloon dilation O 44406- with
endoscopic ultrasound examination, limited to the sigmoid,
descending, transverse, or ascending colon and cecum and adjacent
structures O 44407- with transendoscopic ultrasound guided
intramural or transmural fine needle aspiration/biopsy(s), includes
endoscopic ultrasound examination limited to the sigmoid,
descending, transverse, or ascending colon and cecum and adjacent
structures O 44408- with decompression (for pathologic distention)
(eg, volvulus, megacolon), including placement of decompression
tube, when performed
Slide 84
Digestive
Slide 85
O Endoscopy- Sigmoidoscopy O 45346- Sigmoidoscopy, flexible;
with ablation of tumor(s), polyp(s), or other lesion(s) (includes
pre- and post-dilation and guide wire passage, when performed) O
45347- with placement of endoscopic stent (includes pre- and
post-dilation and guide wire passage, when performed) O 45349- with
endoscopic mucosal resection O 45350- with band ligation(s) (eg,
hemorrhoids)
Slide 86
Digestive O Endoscopy- Colonoscopy O 45388- Colonoscopy,
flexible; with ablation of tumor(s), polyp(s), or other lesion(s)
(includes pre- and post- dilation and guide wire passage, when
performed) O 45389- with endoscopic stent placement (includes pre-
and post-dilation and guide wire passage, when performed) O 45390-
with endoscopic mucosal resection O 45393- with decompression (for
pathologic distention) (eg, volvulus, megacolon), including
placement of decompression tube, when performed O 45398- with band
ligation(s) (eg, hemorrhoids)
Slide 87
Digestive O Endoscopy- Anus O 46600- Anoscopy; diagnostic, with
or without collection of specimen(s) by brushing or washing
(separate procedure)(revised) O 0226T and 0227T have been deleted O
46601- Anoscopy; diagnostic, with high- resolution magnification
(HRA) (eg, colposcope, operating microscope) and chemical agent
enhancement, including collection of specimen(s) by brushing or
washing, when performed O 46607- with biopsy, single or
multiple
Slide 88
Digestive O Colonoscopy and Modifier 52 O For therapeutic
examinations that do not reach the cecum, report the appropriate
therapeutic colonoscopy code with modifier 52 with appropriate
documentation. O Report flexible sigmoidoscopy (45330- 45347) for
endoscopic examination during which the endoscope is not advanced
beyond the splenic flexure.
Slide 89
Digestive O Colonoscopy and Modifier 53 O When performing a
screening or diagnostic endoscopy on a patient who is scheduled and
prepared for a total colonoscopy, if the physician is unable to
advance the colonoscope to the cecum or colon-small intestine
anastomosis due to unforeseen circumstances, report 45378 with
modifier 53 with appropriate documentation.
Slide 90
Urinary 50010-53899
Slide 91
Urinary O 2 new Cystoscopy codes O 52441- Cystourethroscopy,
with insertion of permanent adjustable transprostatic implant;
single implant O 52442- each additional permanent adjustable
transprostatic implant (List separately in addition to code for
primary procedure)
Slide 92
Nervous System 61000-64999
Slide 93
60000 Neurological O Myelography O New myelography codes were
created which include the supervision and interpretation. The
existing code for myelogram injection has been revised and 4 new
codes have been added O 62284- Injection procedure for myelography
and/or computed tomography, spinal lumbar (other than C1-C2 and
posterior fossa) O 62302- Myelography via lumbar injection,
including radiological supervision and interpretation; cervical O
62303 - thoracic O 62304 - lumbosacral O 62305 - 2 or more regions
(eg, lumbar/thoracic, cervical/thoracic, lumbar/cervical,
lumbar/thoracic/cervical)
Slide 94
Radiology 70010-77086
Slide 95
Radiology O Breast Imaging O New codes have been introduced for
breast tomosynthesis. Also, the existing code for breast ultrasound
was deleted and two new codes have been introduced for limited and
complete ultrasound. O 76641 Ultrasound, breast, unilateral, real
time with image documentation, including axilla when performed;
complete O 76642 Ultrasound, breast, unilateral, real time with
image documentation, including axilla when performed; limited O
77061 Digital breast tomosynthesis; unilateral O 77062 Digital
breast tomosynthesis; bilateral O 77063 Screening digital breast
tomosynthesis, bilateral (List separately in addition to code for
primary procedure) (77057) O 76445 has been deleted
Slide 96
Radiology
Slide 97
O Vertebral Fracture Assessment O The existing code for
vertebral fracture assessment (VFA) has been deleted and 2 new
codes have been introduced for 2015. One code represents VFA done
as part of a bone density study and the other is for VFA alone.. O
77085 Dual-energy X-ray absorptiometry (DXA), bone density study, 1
or more sites; axial skeleton (eg, hips, pelvis, spine), including
vertebral fracture assessment O 77086 Vertebral fracture assessment
via dual- energy X-ray absorptiometry (DXA) O 77082 was
deleted
Slide 98
Radiology O New Category III* codes have been introduced for
radiostereometric analysis. O 0348T Radiologic examination,
radiostereometric analysis (RSA); spine, (includes cervical,
thoracic and lumbosacral, when performed) O 0349T Radiologic
examination, radiostereometric analysis (RSA); upper
extremity(ies), (includes shoulder, elbow, and wrist, when
performed) O 0350T Radiologic examination, radiostereometric
analysis (RSA); lower extremity(ies), (includes hip, proximal
femur, knee, and ankle, when performed)
Slide 99
Radiation Oncology 77261-77799
Slide 100
Radiation Oncology O Radiation Therapy O Radiation therapy
codes underwent significant changes for 2015. Teletherapy isodose
planning and brachytherapy codes now include the basic dosimetry
calculation and IMRT codes now include guidance and tracking. Also
radiation treatment delivery codes were deleted in 2015. O 77306
Teletherapy isodose plan; simple (1 or 2 unmodified ports directed
to a single area of interest), includes basic dosimetry
calculation(s) O 77307 Teletherapy isodose plan; complex (multiple
treatment areas, tangential ports, the use of wedges, blocking,
rotational beam, or special beam considerations), includes basic
dosimetry calculation(s) O 77316 Brachytherapy isodose plan; simple
(calculation[s] made from 1 to 4 sources, or remote afterloading
brachytherapy, 1 channel), includes basic dosimetry calculation(s)
O 77305, 77310, 77315, 77326, 77327, 77238 have been deleted
Slide 101
Radiation Oncology O Radiation Therapy O 77317 Brachytherapy
isodose plan; intermediate (calculation[s] made from 5 to 10
sources, or remote afterloading brachytherapy, 2-12 channels),
includes basic dosimetry calculation(s) O 77318 Brachytherapy
isodose plan; complex (calculation[s] made from over 10 sources, or
remote afterloading brachytherapy, over 12 channels), includes
basic dosimetry calculation(s) O 77385 Intensity modulated
radiation treatment delivery (IMRT), includes guidance and
tracking, when performed; simple O 77386 Intensity modulated
radiation treatment delivery (IMRT), includes guidance and
tracking, when performed; complex O 77387 Guidance for localization
of target volume for delivery of radiation treatment delivery,
includes intrafraction tracking, when performed
Slide 102
Pathology and Laboratory 80047-89398
Slide 103
Pathology and Laboratory O The new section in the AMA book
includes the addition of guidelines, parentheticals, and tables
that are used to direct reporting within the 2 new subsections. O
The codes included within these subsections identify drug
procedures according to the purpose of the procedure and type of
patient results obtained. O The Presumptive Drug Class Screening
section includes Guidelines for the Presumptive Drug Class
Screening section, Drug Class List A (which itemizes commonly
assayed drugs within the listing), and Drug Class List B (which
itemizes assays that require more resources than Class A). O This
section also includes guidelines that explain the intended use for
the listing and the codes.
Slide 104
Pathology and Laboratory O The updated reporting mechanism has
been designed to address the following: O ability to be easily
modified for future changes and technological advances O
identification of updated clinical settings O identification of
sources for specimen(s).
Slide 105
Pathology and Laboratory O Microbiology Changes O Along with
several other changes, codes 87623, 87624, 87625 have been added to
report human papilloma virus (HPV) genotyping to differentiate high
and low risk HPV types. O HPV genotyping is used in conjunction
with or as follow-up to an abnormal cytology report. O The existing
HPV codes 87620, 87621 and 87622 have been deleted and replaced
with genotyping codes that describe the specific types test
Slide 106
Pathology and Laboratory O Surgical Pathology Changes O
Immunocytochemistry and immunohistochemistry CPT codes have
undergone additional changes for 2015. O The histomorphometry codes
88360, 88361 for reporting detection of protein receptors for
diagnosing the development of tumor(s) and cancer have been
revised. O The in situ hybridization codes 88365, 88367, 88368 have
been revised and expanded into three separate families of codes
that identify; O 1) the initial single probe stain procedure
(88365, 88367, 88368) O 2) each additional single probe stain
procedure (88364, 88373, 88369) O 3) each multiplex probe stain
procedure (88366, 88374, 88377
Slide 107
Medicine 90281-99607
Slide 108
Medicine O Vaccines O 90651- Human Papillomavirus vaccine types
6, 11, 16, 18, 31, 33, 45, 52, 58, nonavalent (HPV), 3 dose
schedule, for intramuscular use O 90654- Influenza virus vaccine,
split virus, preservative-free, for intradermal use O 90630-
Influenza virus vaccine, quadrivalent (IIV4), split virus,
preservative free, for intradermal use O 90721- Diphtheria, tetanus
toxoids, and acellular pertussis vaccine and Hemophilus influenza B
vaccine (DTaP-Hib), for intramuscular use O 90723- Diphtheria,
tetanus toxoids, acellular pertussis vaccine, Hepatitis B, and
poliovirus vaccine, inactivated (DTaP- HepB-IPV), for intramuscular
use O 90734- Meningococcal conjugate vaccine, serogroups A, C, Y
and W-135 (tetravalent), for intramuscular use
Slide 109
Medicine O 92541: Spontaneous nystagmus test, including gaze
and fixation nystagmus, with recording O 92542: Positional
nystagmus test, minimum of 4 positions, with recording O 92543:
Caloric vestibular test, each irrigation (binaural, bithermal
stimulation constitutes 4 tests), with recording O 92544:
Optokinetic nystagmus test, bidirectional, foveal or peripheral
stimulation, with recording O 92545: Oscillating tracking test,
with recording
Slide 110
Medicine O 97607- Negative pressure wound therapy, (eg, vacuum
assisted drainage collection), utilizing disposable, non-durable
medical equipment including provision of exudate management
collection system, topical application(s), wound assessment, and
instructions for ongoing care, per session; total wound(s) surface
area less than or equal to 50 square centimeters O 97608- total
wound(s) surface area greater than 50 square centimeters
Slide 111
Medicine O 99188- Application of topical fluoride varnish by a
physician or other qualified health care professional