December 2016 / Volume 26 Issue 12 Assistant...4 CPT® Assistant December 2016 / Volume 26 Issue 12...

AMERICAN MEDICAL ASSOCIATION

AssistantOfficial source for CPT coding guidance

December 2016 / Volume 26 Issue 12

In This Issue: 3 Revised Bunionectomy Coding for 2017

9 Nuclear Medicine Parathyroid Gland Studies

11 Psychiatry Changes for 2017

13 Flexible Laryngoscopy (31575-31579)

15 Reporting Mammography Services

16 Frequently Asked Questions

CPT Assistant Editorial Board* Chair: Mark S. Synovec, MDVice Chair, CPT Editorial Panel

Secretary: Danielle Pavloski, RHIT, CCS-PManaging Editor, CPT Assistant American Medical Association

Claudia J. Bonnell, RN, MLS Blue Cross Blue Shield Association

Nelly Leon-Chisen, RHIAAmerican Hospital Association

Simon P. Cohn, MDAmerica’s Health Insurance Plans

Olatokunbo O. Awodele, MD, MPHContractor Medical Director

Joel F. Bradley, MDFormer CPT Editorial Panel

Sean P. Roddy, MDCPT Advisory Committee

Thomas Weida, MD, FAAFPAMA Specialty Society RVS Update Committee

Victor L. Lewis, Jr, MD, FACSCPT Editorial Panel

Marsha Mason-Wonsley, MA, RNCenters for Medicare & Medicaid Services

Karen O’Hara, BS, CCS-PAmerican Medical Association

Daniel Picus, MD, FACR, RCC CPT Advisory Committee

Ira Kraus, DPMHealth Care Professionals Advisory Committee

* Established February 2007. Beginning with the May 2007 issue, all content has been reviewed by the CPT Assistant Editorial Board.

AMA Acknowledgements

James L. Madara, MDExecutive Vice President, Chief Executive Officer

Bernard L. HengesbaughChief Operating Officer

Laurie A. S. McGraw Senior Vice President, Health Solutions Group

Jay Ahlman Vice President, Coding and Reimbursement Policy and Strategy

AMA StaffDanielle Pavloski, RHIT, CCS-P, Managing EditorRejina Young, Editorial Assistant

Contributing StaffAndrei Besleaga, RHIT; Janette Meggs, RHIA; Danielle Pavloski, RHIT, CCS-P; Arletrice Watkins, MHA, RHIA; Rejina Young

Contributing AuthorsAmerican Podiatric Medical Association; Society of Nuclear Medicine and Molecular Imaging; and American College of Nuclear Physicians

Development and Production StaffNancy Baker, Manager, Book and Product Development and ProductionLisa Chin-Johnson, Senior Developmental EditorMary Ann Albanese, Production Specialist

Marketing ManagerSusan Jarrett

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CPT ® AssistantAmerican Medical AssociationAMA Plaza330 North Wabash Avenue, Suite 39300Chicago, IL 60611-5885CPT® Assistant is designed to provide accurate, up-to-date coding information. We continue to make every reasonable effort to ensure the accuracy of the material presented. However, this newsletter does not replace the CPT codebook; it serves only as a guide.

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Cover photograph: Lev Dolgachov/Ingram Publishing; AC29:12/16

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CPT® Assistant December 2016 / Volume 26 Issue 12


3Revised Bunionectomy Coding for 2017

• first ray pathology (eg, congenital or acquired meta-tarsal shorting or lengthening relative to the second metatarsal; hypermobility or instability; metatarsus primus varus [adductus], which is a measured increase in the first intermetatarsal angle)

• malalignment of the first metatarsal sesamoid apparatus.

Because not all hallux valgus deformities are the same, and may include any combination of pathology as noted above, so too are CPT bunionectomy codes differentiated from each other based on complexity, pathology, and the technique(s) required to repair or correct specific deformities present.

Surgical Coding of Bunion Deformity Correction and Related PathologyThe CPT 2017 code set includes significant revisions to the coding and descriptions of hallux valgus (bunionec-tomy) procedures. Bunionectomy procedures include, if performed, the following intraoperative component procedures: first metatarsophalangeal joint capsulotomy; arthrotomy with or without removal of loose bodies or bursal tissue, synovectomy, and/or synovial biopsy; resec-tion of medial, dorsomedial, dorsal, and/or dorsolateral bone prominences at the metatarsal head and proximal phalanx base; excision of associated osteophytes; articular shaving or drilling; extensor and/or flexor tenorrhaphy, adductor hallucis tendon transfer or tenotomy, and/or tenolysis; placement of internal fixation; intraoperative supervision and positioning of imaging and/or monitoring equipment by surgeon or assistant; first metatarsophalangeal joint capsule plication and/or repair; closure of surgical site; and the applications of initial dressing, splint, and/or cast.

Reporting Hallux Valgus (Bunionectomy) CorrectionCPT code 28290 has been deleted for 2017. To report, use code 28292.

p28292 Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with resection of proximal phalanx base, when performed, any method

u(28293 has been deleted. To report, use 28291)t

u(28294 has been deleted. To report, use 28899)t

Hallux valgus (bunion) is a common forefoot deformity, which typically comprised of a bony prominence at the distal metaphysis (head) of the first metatarsal, lateral deviation of the great toe (hallux) at the first metatarsophalangeal joint, and valgus rotation of the hallux. When symptom-atic, this deformity may result in pain, difficulty wearing shoes, and limitation in weight-bearing activities. With over 100 variations of procedures described, Current Procedural Terminology (CPT®) bunionectomy codes are distinguished not only by the severity of the bunion deformity and specific contributing deformities or pathology, but also by the sur-gical techniques performed to correct those deformities.

Bunion EtiologyThe development of a hallux valgus (bunion) deformity may be influenced by both intrinsic and extrinsic factors. Intrinsic causes may include a genetically predisposed foot-type, hypermobility of the first ray (first metatarsal cuneiform joint, first metatarsal, first metatarsophalangeal joint, and great toe), instability or weakness of the muscles and tendons governing the first ray, and the presence of structural deformities (eg, metatarsus primus varus [adductus], or abnormally short or long first metatarsal in relationship to the second metatarsal length).

Examples of extrinsic causes include shoes that constrict or compress the forefoot, work activities (eg, prolonged walking or standing), recreational activities (eg, running, dancing), and direct injury.

Types of Bunion DeformitiesHallux valgus (bunion) deformities vary in pathology and severity, and should be defined in terms of complexity of deformities rather than representing a single deformity. Related pathology that may be present includes:

• bone prominence at the medial, dorsomedial, dorsal, and/or dorsolateral aspect of the first metatarsal head;

• bone prominence at the medial aspect of the base of the hallux proximal phalanx and/or bone spurring at the dorsal and lateral aspect of the base of the hallux proximal phalanx;

• hallux abductus (transverse lateral deviation of the great toe [hallux] at the metatarsophalangeal joint);

• valgus rotation of the hallux;

• hallux abductus interphalangeus (transverse structural lateral deviation at the hallux interphalangeal joint;

• degenerative changes within the first metatarsophalan-geal joint, with or without osteophytes (bony spurring);

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and/or base of the proximal phalanx with or without related soft-tissue correction, resection, or release. (See Figure 1.) The procedure represented by code 28292 may also involve tendon and other soft-tissue balancing; trans-verse resection of the proximal phalanx base; and/or the removal of one or both sesamoids.

Resection of the proximal phalanx base is performed when there is a bunion deformity present, arthritic changes to the first metatarsophalangeal joint, and pain and/or limita-tion of motion in the joint. (See Figure 2.) Code 28292 does not include osteotomy or fusion procedures.

p28296 Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with distal metatarsal osteotomy, any method

CPT code 28296 is the most commonly performed bunio-nectomy procedure (see Figure 3). It is typically performed to correct a mild-to-moderate hallux abductovalgus deformity associated with a mild-to-moderate intermeta-tarsal angle (metatarsus primus varus [adductus]) and/or distal lateral torsional deviation of the metatarsal head. Modifications to the osteotomy may allow for multiplane corrections of structural deformities within the distal first metatarsal.

Code 28292 includes the removal of prominent or hypertrophied bone from the medial aspect of the first metatarsal head (distal metaphysis), and may additionally include the resection of excess bone at the dorsomedial, dorsal, and/or dorsolateral aspect of the metatarsal head

After

Before

Medial eminence of metatarsal bone

Figure 1. Hallux Valgus Correction28292

After

Before

Degenerative jointdisease

Medial eminence of metatarsal bone

Kirschner wire holding joint

Figure 2. Hallux Valgus Correction withProximal Phalanx Base Resection28292

Medialeminence of metatarsalbone

Osteotomy

After

Before

Figure 3. Hallux Valgus Correction withDistal First Metatarsal Osteotomy28296A single or multiple plane osteotomy originatingthrough the distal aspect of the first metatarsal.


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Medialeminence of metatarsalbone

Osteotomy

After

Before

High intermetatarsalangle

Figure 4. Hallux Valgus Correction withProximal First Metatarsal Osteotomy28295

Code 28296 includes the removal of prominent or hyper-trophied bone from the medial aspect of the first metatarsal head (distal metaphysis) along with distal first metatarsal osteotomy, and may additionally include the resection of excess bone at the dorsomedial, dorsal, and/or dorsolateral aspect of the metatarsal head, and/or base of the proximal phalanx with or without related soft-tissue correction, resection, or release. The procedure represented by code 28296 may also involve tendon and other soft-tissue bal-ancing and/or removal of one or both sesamoids.

An osteotomy is defined as the surgical cutting of bone. A distal first metatarsal osteotomy is defined by its distal most cut occurring within the distal 50% of the bone. Two osteotomies performed to remove a single wedge or cylinder of bone are considered a single osteotomy.

#l28295 Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with proximal metatarsal osteotomy, any method

The procedure represented by code 28295 is typically performed to correct a moderate-to-severe hallux abduc-tovalgus deformity with an associated high intermetatarsal angle (metatarsus primus varus [adductus]). Modifications to the osteotomy may allow for multiplane corrections of structural deformities within the proximal first metatarsal.

Code 28295 includes the removal of prominent or hyper-trophied bone (bunion) from the medial aspect of the first metatarsal head (distal metaphysis) along with proximal first metatarsal osteotomy, and may additionally include the resection of excess bone at the dorsomedial, dorsal, and/or dorsolateral aspect of the metatarsal head, and/or base of the proximal phalanx with or without related soft-tissue correction, resection, or release. (See Figure 4.) Code 28295 may also involve tendon and other soft-tissue balancing and/or the removal of one or both sesamoids.

p28297 Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with first metatarsal and medial cuneiform joint arthrodesis, any method

The procedure represented by code 28297 is performed to correct a hallux abductovalgus deformity with associated long first metatarsal, hypermobile first ray or instability in the first metatarsocuneiform joint, high medially deviated first metatarsocuneiform angle, arthritic changes in the first metatarsocuneiform joint, and/or failed first ray oste-otomy. (See Figure 5.) Modifications to the osteotomy may allow for multiplane corrections of structural deformities within the proximal first metatarsal.

Code 28297 includes the removal of prominent or hyper-trophied bone from the medial aspect of the first metatarsal head (distal metaphysis) along with first metatarsal and

Medialeminenceof metatarsalbone

Arthrodesisof the firstmetatarsaland firstcuneiform joint

After

Before

Figure 5. Hallux Valgus Correction withMetatarsal-Medial Cuneiform Joint Arthrodesis28297

medial cuneiform joint arthrodesis, and may additionally include the resection of excess bone at the dorsomedial, dorsal, and/or dorsolateral aspect of the metatarsal head, and/or base of the proximal phalanx with or without related soft-tissue correction, resection, or release. An

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p28299 Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with double osteotomy, any method

The procedure represented by code 28299 is performed to correct a moderate to severe hallux abductovalgus deformity with associated multilevel first ray deformities, including a mild to high intermetatarsal angle (meta-tarsus primus varus [adductus]) with or without a high hallux abductus interphalangeal angle. (See Figure 7.) Modifications to the osteotomies may allow for multiplane

arthrodesis is defined as the surgical fusion of a joint or adjacent bones. A first metatarsocuneiform arthrodesis is not a proximal first metatarsal osteotomy. Code 28297 may also involve tendon and other soft-tissue balancing and/or the removal of one or both sesamoids.

p28298 Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with proximal phalanx osteotomy, any method

The procedure represented by code 28298 is performed to correct a mild-to-moderate hallux abductovalgus deformity typically associated with a high hallux abductus inter-phalangeal angle (ie, a lateral deviation of the hallux due to lateral torsional deformity in the proximal phalanx). (See Figure 6.) Modifications to the orientation of the osteotomy may allow for uni- or multiplane corrections of structural deformities within the proximal phalanx.

Code 28298 includes the removal of prominent or hyper-trophied bone from the medial aspect of the first metatarsal head (distal metaphysis) along with proximal phalanx oste-otomy to correct the bone orientation, and may additionally include the resection of excess bone at the dorsomedial, dorsal, and/or dorsolateral aspect of the metatarsal head, and/or base of the proximal phalanx with or without related soft-tissue correction, resection, or release. Code 28298 may also involve tendon and other soft-tissue balancing and/or the removal of one or both sesamoids.

Before

After

Bone screw option

Medial eminenceof metatarsal bone

Proximal phalanx

Figure 6. Hallux Valgus Correction with Proximal Phalanx Osteotomy28298

PREOP

Angular deformityof proximalphalanx

Medialeminence ofmetatarsalbone

Note: Internal fixation is not depicted, but would include screw(s), pin(s), wire(s), as needed.

POSTOP

Osteotomyproximal phalanx

Osteotomydistal firstmetatarsal

Surgical Option 1

PREOP

Medial eminenceof metatarsalbone


POSTOP

Double osteotomyof the metatarsalwith internalfixation

Surgical Option 2

PREOP


POSTOP

Osteotomyproximal phalanx

Osteotomyproximal firstmetatarsal

Angular deformityof proximalphalanx

Medialeminence ofmetatarsalbone

Angulardeformity at thefirst metatarsalbase

Surgical Option 3

Figure 7. Hallux Valgus Correctionwith Double Osteotomy28299These illustrations depict medial resection of the first metatarsalalong with several first ray double osteotomy options for hallusvalgus and metatarsus primus adductus (high intermetatarsalangle) correction.


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corrections of structural deformities within the first meta-tarsal or proximal phalanx.

Code 28299 includes the removal of prominent or hyper-trophied bone from the medial aspect of the first metatarsal head (distal metaphysis) along with double osteotomies performed within the first ray, and may additionally include the resection of excess bone at the dorsomedial, dorsal, or dorsolateral aspect of the metatarsal head, and/or base of the proximal phalanx with or without related soft-tissue correction, resection, or release. The procedure represented by code 28299 may also involve tendon and other soft-tissue balancing and/or the removal of one or both sesamoids.

Code 28299 includes three double osteotomy options:

1. distal first metatarsal osteotomy and proximal phalanx osteotomy;

2. distal first metatarsal osteotomy and proximal first metatarsal osteotomy; or

3. proximal first metatarsal osteotomy and proximal phalanx osteotomy.

NonBunionectomy–Related Procedures p28289 Hallux rigidus correction with cheilectomy,

debridement and capsular release of the first metatarsophalangeal joint; without implant

A cheilectomy is performed at the first metatarsophalan-geal joint, when arthritic changes result in significant reduction in motion (hallux limitus) in the joint. Patients typically report pain on motion. The procedure involves the resection of osteophytic proliferation, including any fragmentation at the dorsal distal aspect of the first meta-tarsal and/or dorsal proximal phalanx base with secondary remodeling of bone on the medial and/or lateral aspects of both the first metatarsal head and base of the proximal phalanx. (See Figure 8.) Any adhesions involving the sesa-moid apparatus are released. With the dorsal osteophytic block removed, the range of motion of the joint should be significantly increased.

l28291 Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint; with implant

Before

After

Removal of bone

Lateral view

Lateral view

Distal dorsal metatarsal osteophytes withdegenerative changes

Proximal phalanx basewith dorsal osteophytes

Figure 8. Hallux Rigidus Correction28289

A cheilectomy (surgical removal of abnormal bone around a joint in order to facilitate joint mobility) with implant procedure is performed at the first metatarsophalangeal joint when arthritic changes result in either a significant reduction in motion (hallux limitus) or a lack of motion in the joint (hallux rigidus). Patients typically report pain in the joint with attempts of motion. The procedure involves the resection of osteophytic proliferation, including any fragmentation at the dorsal, medial, and/or lateral distal aspect of the first metatarsal, while the base of the prox-imal phalanx is resected. The addition of an implant is intended to improve joint motion and stabilize joint align-ment. If an interpositional implant (single- or hemi-semi) is utilized, it is inserted into the medullary canal of the proximal phalanx. If a double-stem or total-joint implant is utilized in addition to the base of the proximal phalanx, the distal portion of the first metatarsal is resected and the phalanx stem of the implant is inserted into the medul-lary canal of the proximal phalanx. The metatarsal stem of the implant is then inserted into the medullary canal of

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Before

After

Implant(s)

Lateral view

Lateral view

Distal dorsal metatarsal osteophytes withdegenerative changes

Proximal phalanx basewith dorsal osteophytes

Figure 9. Hallux Rigidus Correction with Implant28291A single- or double-stem implant may be used.

the distal first metatarsal. Code 28291 represents a hallux rigidus correction with cheilectomy and implant, regardless of implant type or material used. (See Figure 9.)

28750 Arthrodesis, great toe, metatarsophalangeal joint

While not a bunionectomy procedure, arthrodesis of the first metatarsophalangeal joint is a procedural option for eliminating first metatarsophalangeal degenerative joint disease (arthritis), limited range of motion, and pain. A bunion deformity with or without hallux abductovalgus may or may not be present.u

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to the patient. When reporting the administration of a diagnostic radiopharmaceutical, it is important to report on the claim form the date the radiopharmaceutical was actually administered, rather than the date of service of the imaging, which could be on a different day. This is standard reporting for diagnostic radiopharmaceuticals for all nuclear medicine procedures.

Table 1. Diagnostic Radiopharmaceuticals Used for Parathyroid Studies

HCPCS Level II Code

Description Comments

A9500 Technetium Tc-99m sestamibi, diagnostic, per study dose

Per study dose (PSD), means typical reporting unit is 1, as there is a range of millicuries administered.

A9502 Technetium Tc-99m tetrofosmin, diagnostic, per study dose

PSD means the typical reporting is 1, as a range of millicuries may be administered.

A9505 Thallium Tl-201 thallous chloride, diagnostic, per millicurie

Report the number of units, as this radiotracer is reported per millicurie (mCi) administered rather than PSD. Multiple units may apply (eg, to report 3 mCi at stress and 1 mCi for redistribution, report 4 units total).

A9512 Technetium Tc-99m pertechnetate, diagnostic, per millicurie

Pay attention to the number of units reported, as this radiotracer is reported per millicurie administered, rather than per study dose. Multiple units may apply.

A9516 Iodine I-123 sodium iodide, diagnostic, per 100 microcuries, up to 999 microcuries

Report the number of microcuries administered in increments of 100 microcuries. This radiotracer is reported per 100 microcuries, rather than per study or per millicurie. Multiple units may apply (eg, to report 300 microcuries, use 3 units, to report 328 microcuries report 4 units).

Coding TipIt is appropriate to report a general description nuclear medi-cine CPT code, if there is no organ-specific code. However, if an organ-specific code exists, the organ-specific code must be reported.

A parathyroid gland study is used in nuclear medicine to identify and localize abnormally functioning parathyroid gland tissue. The parathyroids are four small glands lying close to or embedded in the back surface of the thyroid gland, which is situated in the front of the neck. All nuclear medicine diagnostic tests are functional studies. Nuclear medicine parathyroid studies primarily are used to localize hyperfunctioning parathyroid tissue (usually adenomas) in patients with persistent or recurrent disease. Since 2013, parathyroid imaging techniques, protocols, and use of a variety of diagnostic radiopharmaceuticals (also called radiotracers or isotopes) have evolved.1

It is important to understand the definitions of some terms often used in parathyroid study report:

• Planar imaging is two-dimensional functional imaging;

• Single photon emission computed tomography (SPECT) is three-dimensional functional imaging; and

• SPECT/CT is a SPECT study that utilizes computed tomography (CT) for both attenuation correction and for anatomical localization assistance.

As with all nuclear medicine Current Procedural Terminology (CPT®) codes, a SPECT or SPECT/CT study includes limited planar imaging, and it is not reported separately. “Dual-phase” or “double-phase” imaging refers to the acquisition of both early and delayed imaging, while “dual-isotopes” or “subtraction” imaging refers to protocols using two different diagnostic radiopharmaceuticals. “Non-imaging” or “probe technique” includes the injection of a radiotracer followed by the use of a gamma probe to detect the location of the radiotracer. This technique is often used by a surgeon during an operative procedure and may be performed with or without imaging.

Diagnostic Radiopharmaceuticals Used in Parathyroid StudiesAs stated in the introductory section of the Radiology: Nuclear Medicine subsection of the CPT code set, “The services listed do not include the radiopharmaceutical or drug. To separately report supply of diagnostic and thera-peutic radiopharmaceuticals and drugs, use the appropriate supply code(s), in addition to the procedure code” (CPT® 2017, p 471). Table 1 lists the six diagnostic radiopharma-ceuticals that may be used today for parathyroid studies. Providers report each diagnostic radiopharmaceutical used for the procedure with units representative of the HCPCS code description and radiotracer administered

Nuclear Medicine Parathyroid Gland Studies

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Appropriate coding for parathyroid imaging depends on the protocol/imaging technique(s) used and the date of service of the procedure. If a planar technique is performed alone (eg, single-phase or dual-phase [early and late] imaging of the neck and mediastinum), report code 78070, Parathyroid planar imaging (including subtraction, when performed). If a SPECT technique (eg, single-phase or dual-phase [early and late] imaging of the neck and mediastinum) with limited planar imaging is performed on a date of service prior to January 1, 2013, report code 78803, Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s); tomographic (SPECT).

If a SPECT/CT technique (eg, single-phase or dual-phase [early and late] imaging of the neck and mediastinum) with limited planar imaging is performed on a date of service prior to January 1, 2013, report code 78803, Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s); tomographic (SPECT) plus code 78999, Unlisted miscellaneous procedure, diagnostic nuclear medicine, for the “fusion” of the SPECT study with the CT study for anatomical localization. For parathyroid injections with no imaging (eg, probe identification in the operating room) performed on a date of service prior to January 1, 2009, report unlisted code 78099, Unlisted endocrine procedure, diagnostic nuclear medicine, as there are no codes to describe the intravenous injection of a patient prior to surgery with no imaging for localization during surgery using a probe. Table 2 lists the current CPT codes to report parathyroid studies.

Table 2. Current CPT Codes for Parathyroid StudyCPT Code Description Comments

78070 Parathyroid planar imaging (including subtraction, when performed);

Minor editorial changes effective January 1, 2013.

78071 Parathyroid planar imaging (including subtraction, when performed); with tomographic (SPECT)

Replaces code 78803; new code effective January 1, 2013.

78072 Parathyroid planar imaging (including subtraction, when performed); with tomographic (SPECT), and concurrently acquired computed tomography (CT) for anatomical localization

Replaces the reporting of code 78803 plus code 78999; new bundled code effective January 1, 2013.

78808 Injection procedure for radiopharmaceutical localization by non-imaging probe study, intravenous (eg, parathyroid adenoma)

Replaces code 78099; new code effective January 1, 2009.

Coding TipWhen reporting an unlisted procedure code, it is necessary to submit supporting documentation (eg, procedure report) along with the claim to provide an adequate description of the nature, extent, and need for the procedure, and the time, effort, and equipment necessary to provide the service.

Current Reporting The new and revised parathyroid CPT codes implemented in 2013 accurately reflect today’s practice and services provided. As stated previously, appropriate coding for parathyroid imaging continues to depend on the protocol or imaging technique(s) used, and the date of service of the procedure. If a planar technique is performed alone (eg, dual-phase imaging of the neck and mediastinum), report code 78070, Parathyroid planar imaging (including subtraction, when performed). If a SPECT technique (eg, dual-phase imaging of the neck and mediastinum) with limited planar imaging is performed, report code 78071, Parathyroid planar imaging (including subtraction, when performed); with tomographic (SPECT). Finally, if a SPECT/CT is performed for anatomical localization of the para-thyroids, rather than a SPECT study alone as noted earlier, report code 78072, Parathyroid planar imaging (including subtraction, when performed); with tomographic (SPECT), and concurrently acquired computed tomography (CT) for anatomical localization.

Effective January 1, 2009, the American Medical Association (AMA) CPT Editorial Panel implemented code 78808, Injection procedure for radiopharmaceutical localization by non-imaging probe study, intravenous (eg, parathyroid adenoma), for parathyroid injections with no imaging (eg, probe identification in the operating room). Note that codes 78070, 78071, and 78072 include the injec-tion of the tracer(s); therefore, do not report code 78808 with codes 78070, 78071, and 78072, as it is inherent in these codes.u

References

1. Greenspan BS, Dillehay G, Intenzo C, et al. SNM practice guideline for parathyroid scintigraphy 4.0. J Nucl Med Technol. 2012 Jun;40(2):111-8. Available at: http://snmmi.files.cms-plus.com/docs/Parathyroid_Scintigraphy_V4_0_FINAL.pdf.


11psychotherapy includes interactive complexity services)

Hp90846 Family psychotherapy (without the patient present), 50 minutes

Hp90847 Family psychotherapy (conjoint psychotherapy) (with patient present), 50 minutes

Guideline RevisionsThroughout the psychotherapy guidelines, references to “family member” have been removed and replaced with the term “informant” to help clarify the distinction between individual and family psychotherapy. This revision rein-forces the assumption that when individual psychotherapy is provided, the focus is on the patient and not on the patient’s family members. The guidelines further clarify that when reporting individual psychotherapy, the patient is required to be present for all or a majority of the service, instead of for only some of the service; thus, time reporting is a factor. The guideline revisions also direct attention to codes 90846 and 90847 for reporting family psychotherapy techniques and family dynamics. Finally, the guidelines have been revised to include instruction on how to report both types of services (individual and family psycho-therapy) when these services are separately provided on the same day. Codes 90832, 90833, 90834, 90836, 90837, and 90838 may be reported on the same day as codes 90846 and 90847, when the services are separate and distinct.

Time ReportingAs defined in the Introduction to the CPT codebook, “When codes are ranked in sequential typical times and the actual time is between two typical times, the code with the typical time closest to the actual time is used” (CPT® 2017, p xv). A unit of time is attained when the mid-point is passed.

Codes 90832, 90833, 90834, 90836, 90837, and 90838 are time-based codes that describe psychotherapy for the individual patient. The times delineated by these codes are for face-to-face services with the patient. Even though the services may include informant(s), the patient must be present for all or a majority of the service. During indi-vidual psychotherapy, because the patient is the main focus of the psychotherapy service, the patient is required to be present for 16 to 37 minutes when codes 90832 and 90833 are reported, 38 to 52 minutes when codes 90834 and 90836 are reported, and 53 or more minutes when codes 90837 and 90838 are reported. (See Table 1.)

In 2013, the Psychiatry section of the Current Procedural Terminology (CPT®) code set has been significantly revised. This section continues to evolve to provide granu-larity to allow appropriate reporting of these services. For 2017, code revisions have been made to distinguish the reporting of codes 90832, 90833, 90834, 90836, 90837, and 90838 for “individual psychotherapy” and codes 90846 and 90847 for “family psychotherapy.” Also, related guidelines have been revised to provide direction on how to report the time spent providing these services. This article provides an overview of these changes.

Hp90832 Psychotherapy, 30 minutes with patient

H✚p90833 Psychotherapy, 30 minutes with patient when performed with an evaluation and management service (List separately in addition to the code for primary procedure)

(Use 90833 in conjunction with 99201-99255, 99304-99337, 99341-99350)





(Use the appropriate prolonged services code [99354, 99355, 99356, 99357] for psychotherapy services not performed with an E/M service of 90 minutes or longer face-to-face with the patient)



(Use 90785 in conjunction with 90832, 90833, 90834, 90836, 90837, 90838 when

Psychiatry Changes for 2017

12


Individual PsychotherapyThe phrase “and/or family member” has been removed from the descriptions of the psychotherapy codes 90832, 90833, 90834, 90836, 90837, and 90838, in order to differentiate between individual and family psychotherapy services. This revision eliminates the confusion that individual psycho-therapy could focus on the patient’s family members. These codes should only be reported when the individual patient is seen for psychotherapy service.

Coding TipPsychotherapy services may be reported on the same day as an E/M service. Select the type and level of E/M service based on the history, examination, and medical decision-making. (See Figure 1.)u

Table 1. CPT Time RuleCPT Codes Total Duration of

Psychotherapy Time90832, 90833 16-37 minutes90834, 90836 38-52 minutes90837, 90838 53 or more minutes90846, 90847 26 or more minutes

Codes 90846 and 90847 are time-based codes and should be used when the focus of therapy is on family dynamics or subsystems within the family (eg, the parental couple or the children) through the use of family psychotherapy techniques. However, the service is always provided for the benefit of the patient. These codes should not be reported for family psychotherapy services lasting less than 26 minutes.

The examples that follow illustrate time reporting for psychotherapy services.

Example 1The patient is seen for 40 minutes in the office for psychotherapy.

In this instance, code 90834, Psychotherapy, 45 minutes with patient, is reported.

Example 2The patient is seen in the office for an E/M visit with psy-chotherapy. The nature of the patient’s presenting problem and documentation meets the criteria to report code 99212, Office or other outpatient visit for the evaluation and man-agement of an established patient, which requires at least 2 of these 3 key components: a problem focused history; a problem focused examination; straightforward medical decision making. In addition to the time spent on the E/M portion of the visit, 20 minutes is spent providing psychotherapy services.

In this instance, both code 99212 and add-on code 90833, Psychotherapy, 30 minutes with patient when performed with an evaluation and management service (List separately in addi-tion to the code for primary procedure), are reported.

Coding TipDo not report psychotherapy of less than 16 minutes’ duration.

Psychotherapy withPatient

Psychotherapy90832 (30 minutes)90834 (45 minutes)90837 (60 minutes)

E/M with Psychotherapy+90833 (30 minutes)+90836 (45 minutes)+90838 (60 minutes)

When an E/M service isprovided on the same day,

report:99201-99255, 99304-99337, 99341-99350

Select the type and levelof E/M based on history,

examination, and medicaldecision-making.

Select the psychotherapyadd-on code based on

time

Note: The same diagnosis mayexist for both psychotherapy

and E/M services.

Figure 1. E/M with Psychotherapy


13 u(To report flexible endoscopic evaluation with

sensory testing, see 92614-92615)t

u(To report flexible endoscopic evaluation of swallowing with sensory testing, see 92616-92617)t

u(For flexible laryngoscopy as part of flexible endoscopic evaluation of swallowing and/or laryngeal sensory testing by cine or video recording, see 92612-92617)t

#l31573 with therapeutic injection(s) (eg, chemodenervation agent or corticosteroid, injected percutaneous, transoral, or via endoscope channel), unilateral

#l31574 with injection(s) for augmentation (eg, percutaneous, transoral), unilateral

p31579 Laryngoscopy, flexible or rigid telescopic, with stroboscopy

The CPT guidelines for endoscopic procedures state that flexible laryngoscopy includes examination of the tongue base, larynx, and hypopharynx. New revisions to the introductory language of the Larynx’s Endoscopy subsection of the Respiratory System section clarify that the anatomic structures examined include both midline (single anatomic sites) and paired structures. Midline, single anatomic sites include the tongue base, vallecula, epiglottis, subglottis, and posterior pharyngeal wall. Paired structures include true vocal cords, arytenoids, false vocal cords, ventricles, pyriform sinuses, and aryepiglottic folds. For the purposes of reporting therapeutic interventions, all paired structures contained within one side of the larynx or pharynx are considered unilateral. When the operating microscope, telescope, or both, are used, the applicable code is reported only once per operative session.

Clinical Example (31572)A 37-year-old female has a history of recurrent laryngeal papillomatosis, which is symptomatic. Flexible laryngos-copy with laser ablation of the papillomas is performed.

Description of Procedure (31572)After allowing time for the anesthetic and decongestant agents to take effect, the flexible laryngoscope is passed through the selected nostril. The nasopharynx with eusta-

For 2017, changes have been made to the Larynx’s Endoscopy subsection of the Respiratory System section of the Current Procedural Terminology (CPT®) code set, which resulted from a Centers for Medicare & Medicaid Services (CMS) high-volume screen to identify potentially misvalued codes. Codes 31575 and 31579 were identified by CMS as being potentially misvalued. As a result of this identification, the entire Respiratory System flexible laryngoscopy code family has been reviewed and revi-sions and appropriate deletions have been made. Among other changes, codes 31575-31577 have been revised by removing the word “fiberoptic” from the code descriptors. This specific change is intended to clarify that both flexible fiberoptic and flexible distal-chip laryngoscopes may be used to perform these procedures. In addition, codes 31572-31574 have been established to report flexible laryngoscopy with ablation and destruction of lesion, therapeutic injection(s), and injections for augmentation, respectively. Thus, a significant number of services previously reported with unlisted code 31599 will be represented by one of the new codes. Therefore, the overall intent of these changes is to update this code family to reflect current practice. In addition, in concert with these changes, several parentheti-cals have been revised as well.

p31575 Laryngoscopy, flexible; diagnostic

u(Do not report 31575 in conjunction with 31231, unless performed for a separate condition using a separate endoscope)t

u(Do not report 31575 in conjunction with 31572, 31573, 31574, 31576, 31577, 31578, 43197, 43198, 92511, 92612, 92614, 92616)t

p31576 with biopsy(ies)

u(Do not report 31576 in conjunction with 31572, 31578)t

p31577 with removal of foreign body(s)

p31578 with removal of lesion(s), non-laser

#l31572 with ablation or destruction of lesion(s) with laser, unilateral

u(Do not report 31572 in conjunction with 31576, 31578)t

u(To report flexible endoscopic evaluation of swallowing, see 92612-92613)t

Flexible Laryngoscopy (31575-31579)

14


the anesthesia to take effect. The injection needle is passed beside the endoscope and through the working side channel. The syringe is depressed, and the therapeutic agent is delivered into the appropriated area until the desired amount is injected. The needle and/or the entire flexible endoscope along with the needle are removed. The needle and the entire laryngoscope are reinserted as needed for additional injections.

Clinical Example (31574)A 45-year-old male has undergone cervical spine surgery. He awoke dysphonic. On examination, reduced movement of the right vocal cord is noted. His voice is not adequate for daily function. Flexible laryngoscopy with vocal cord augmentation with a filler substance is performed.

Description of Procedure (31574)After allowing time for the anesthetic and decongestant agents to take effect, the flexible laryngoscope is passed through the selected nostril. The nasopharynx with eusta-chian tubes are examined. The posterior wall is examined, looking for masses or abnormal adenoid size, palatal eleva-tion, closure, and lateral wall movement. The oropharynx is examined, looking at palatal/uvular length and tonsillar size. The hypopharynx is examined, looking at the lateral pharyngeal walls, pyriform sinuses, laryngeal elevation, and postcricoid area at rest, during phonation, and during swallowing. The larynx, including the epiglottis, petiole, false vocal folds, ventricles, true vocal folds, subglottic region, and upper trachea, is examined. An examination is performed at rest, during phonation, and during swal-lowing. The vocal fold appearance, mucus consistency and amount, vocal fold mobility, sensation, glottic competence, and posterior glottic mucosa are assessed. An appropriate period is allowed for the anesthesia to take effect. Injection augmentation may be performed through a transoral approach, percutaneous transluminal approach, or percu-taneous submucosal approach. If transoral or transluminal approaches are chosen, under flexible endoscopic guidance, the topical anesthesia is applied to the larynx either by dripping lidocaine, 2% or 4%, through a catheter inserted beside the endoscope or into the working side channel of the flexible laryngoscope or by injected the lidocaine percutaneously into the supraglottis, cervical trachea, or subglottis. If the lidocaine is dripped from above, the patient is asked to phonate sustained vowels to keep the anesthetic agent on the vocal folds. A wheal of anesthetic agent may also be infiltrated into the cervical skin if desired. After an appropriate period for the anesthesia to be completed, the injection needle is inserted into the lateral aspect of the vocal fold to be injected. Injection augmen-tation is undertaken with the desired substance until the desired anatomic or voicing effect is achieved. The needle and the entire flexible endoscope are removed.u

chian tubes are examined. The posterior wall is examined, looking for masses or abnormal adenoid size, palatal eleva-tion, closure, and lateral wall movement. The oropharynx is examined, looking at palatal/uvular length and tonsillar size. The hypopharynx is examined, looking at the lateral pharyngeal walls, pyriform sinuses, laryngeal elevation, and postcricoid area at rest, during phonation, and during swallowing. The larynx, including the epiglottis, petiole, false vocal folds, ventricles, true vocal folds, subglottic region, and upper trachea, is examined. An examination is performed at rest, during phonation, and during swal-lowing. The vocal fold appearance, mucus consistency and amount, vocal fold mobility, sensation, glottic competence, and posterior glottic mucosa are assessed.

Anesthesia is applied around the lesion by dripping topical lidocaine through a catheter inserted through the working side channel of the flexible laryngoscope. An appropriate period is allowed for the anesthesia to take effect. The laser fiber is inserted through the side channel. Laser safety precautions according to ANSI standards are used. Laser energy is applied to the area to be ablated or until the desired effect is achieved.

Clinical Example (31573)A 70-year-old female presents with voice changes after intubation for cholecystectomy. Examination reveals a traumatic injury to a vocal cord, with severe inflammation. Flexible laryngoscopy with injection of steroids into a vocal cord is performed.

Description of Procedure (31573)After allowing time for the anesthetic and decongestant agents to take effect, the flexible laryngoscope is passed through the selected nostril. The nasopharynx with eusta-chian tubes are examined. The posterior wall is examined, looking for masses or abnormal adenoid size, palatal eleva-tion, closure, and lateral wall movement. The oropharynx is examined, looking at palatal/uvular length and tonsillar size. The hypopharynx is examined, looking at the lateral pharyngeal walls, pyriform sinuses, laryngeal elevation, and postcricoid area at rest, during phonation, and during swallowing. The larynx, including the epiglottis, petiole, false vocal folds, ventricles, true vocal folds, subglottic region, and upper trachea, is examined. An examination is performed at rest, during phonation, and during swal-lowing. The vocal fold appearance, mucus consistency and amount, vocal fold mobility, sensation, glottic competence, and posterior glottic mucosa are assessed.

Anesthesia is applied around the lesion to be biopsied by dripping topical lidocaine through a catheter that is inserted through the working side channel of the flex-ible laryngoscope. An appropriate period is allowed for


15tion or whether any images require repeating due to motion unsharpness, inadequate positioning, or artifacts. While the patient is in the department or facility, the current diagnostic images are evaluated to determine if they resolve the focal asymmetry seen previously as overlapping breast tissue or if an abnormality that requires further attention persists. It is determined whether additional diagnostic views are necessary; this is reviewed with the technologist. The current diagnostic and recent screening examinations are compared with any older examinations to evaluate for stability or interval change, or any additional suspicious findings. CAD is activated. Any areas CAD has flagged for additional consideration are evaluated. The areas on the current examination are compared with recent screening mammograms and any older examinations. The new images are compared with the contralateral side to assess for symmetry. Recommendations are formulated, and an examination report is dictated. In states with dense breast notification legislation, required verbiage informing the referring provider that his or her patient has dense breast tissue is included.

Clinical Example (77066)A 53-year-old female with bilateral breast lumps palpated by her primary care provider presents for bilateral diag-nostic mammography with CAD.

Description of Procedure (77066)It is determined whether the diagnostic mammographic images are of adequate quality for interpretation or whether any images require repeating due to motion unsharpness, inadequate positioning, or artifacts. While the patient is in the department or facility, the current diagnostic images are evaluated to determine if there are abnor-malities, post-surgical changes, normal variants, or other imaging findings in the areas of clinical concern that would account for the clinical findings or if an abnormality that requires further attention persists. It is determined whether additional diagnostic views are necessary; this is reviewed with the technologist. The remainder of both breasts is assessed. The current diagnostic examinations are compared with any older examinations to evaluate for stability or interval change, or any additional suspicious findings. CAD is activated. Any areas CAD has flagged for additional consideration are evaluated. The areas on the current examination are compared with any older examinations. Recommendations are formulated, and an examination report is dictated. In states with dense breast notification legislation, required verbiage informing the referring provider that his or her patient has dense breast tissue is included.

In the Current Procedural Terminology (CPT®) 2017 code set, the breast mammography imaging codes have been restructured. Changes occurred in the mammog-raphy family with respect to the conversion from analog to digital imaging and the prevalence of computer-aided detection (CAD). CAD is now typically performed with mammography. Thus, three new codes (77065, 77066, and 77067) have been added to combine mammography and CAD into single codes, reflecting the current standard of care. As a result of this bundling, the previous mam-mography CPT codes 77055, 77056, and 77057 and CAD add-on codes 77051 and 77052 have been deleted.

Mammography services with CAD are used for both the detection of breast cancer in asymptomatic patients (screening) and evaluation of patients with an abnormal mammogram or signs and symptoms of breast cancer (diagnostic).

To aid the user, three instructional parentheticals following codes 77062, Digital breast tomosynthesis; bilateral, and 77063, Screening digital breast tomosynthesis, bilateral (List separately in addition to code for primary procedure), have been revised to crosswalk to the new codes.

Review the codes and the following clinical examples for a better understanding of these new codes.

Breast, Mammography l77065 Diagnostic mammography, including computer-

aided detection (CAD) when performed; unilateral

l77066 bilateral

l77067 Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed

u(For electrical impedance breast scan, use 76499)t

Clinical Example (77065)A 67-year-old asymptomatic female recalled from a screening mammogram for a unilateral focal asymmetry presents for further evaluation with unilateral diagnostic mammography with computer-aided detection (CAD).

Description of Procedure (77065)It is determined whether the diagnostic mammographic images of that side are of adequate quality for interpreta-

Reporting Mammography Services

continued on page 17

16


Frequently Asked QuestionsSurgery: Integumentary SystemQuestion: What CPT code should be used to report a breast biopsy, when the only guidance used is tomographic guidance?

Answer: Currently there is no CPT code available to report a tomographic-guided breast biopsy. Therefore, when tomosynthesis is the only imaging guidance used during the breast biopsy, code 19499, Unlisted procedure, breast, should be reported. When reporting an unlisted procedure code, it is necessary to submit supporting documentation (eg, procedure report) along with the claim to provide an adequate description of the nature, extent, and need for the procedure, and the time, effort, and equipment neces-sary to provide the service.

Surgery: Musculoskeletal SystemQuestion: Should code 27654, Repair, secondary, Achilles tendon, with or without graft, be reported for a simple repair of a chronic Achilles tear (re-tear), or should it be reported only for a reconstruction of the Achilles tendon requiring a graft?

Answer: Yes, based on the code descriptor, code 27654 may be reported when performed for a secondary repair of the Achilles tendon, regardless whether a graft is used.

Question: Is it appropriate to report code 29999, Unlisted procedure, arthroscopy, for an abrasion arthroplasty of the glenoid when a debridement of a partial tear of the antero-inferior labrum and subacromial decompression was also performed at the same time?

Answer: No. It is not appropriate to report code 29999 for the abrasion arthroplasty, as this procedure is included as part of the debridement and decompression procedure reported with code 29823, Arthroscopy, shoulder, surgical; debridement, extensive. The debridement and decompres-sion procedure is considered an extensive procedure and includes the following additional components: removal of osteochondral and/or chondral bodies, biceps tendon and rotator cuff debridement, and abrasion arthroplasty.

Question: What is the appropriate code to report the removal of diseased and damaged tendon or fascia tissue, which is performed using an ultrasound guided micro tip device (a tool that utilizes ultrasonic energy to remove damaged tissue)?

Answer: There is no specific CPT code that accurately describes this service. Therefore, the appropriate unlisted code should be reported based on the anatomical loca-tion (eg, 27899, Unlisted procedure, leg or ankle). When reporting an unlisted code to describe a procedure or service, it will be necessary to submit supporting docu-mentation (eg, procedure report) along with the claim to provide an adequate description of the nature, extent,

need for the procedure, and the time, effort, and equip-ment necessary to provide the service.

Radiology: Nuclear MedicineQuestion: Is it correct to report code 78803, Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s); tomographic (SPECT), for SPECT and/or SPECT/CT parathyroid studies?

Answer: No. It is not appropriate to report code 78803 for SPECT or SPECT/CT parathyroid studies. The correct code to report is code 78071, Parathyroid planar imaging (including subtraction, when performed); with tomographic (SPECT), or code 78072, Parathyroid planar imaging (including subtraction, when performed); with tomographic (SPECT), and concurrently acquired computed tomography (CT) for anatomical localization.

Question: We are using code 78070, Parathyroid planar imaging (including subtraction, when performed), to report our parathyroid imaging. Multiple scans are obtained after the injection at different times. Is it appropriate to report code 78070 repeatedly within a 24-hour period for the professional component?

Answer: No, it is not appropriate to report code 78070 repeatedly (two or more units), as multiple imaging is common and inherent to the service. The same is true for codes 78071 and 78072. For each of these codes, when only the professional component of the service is per-formed, append modifier 26, Professional Component, to the CPT code.

Question: Should the use of code 78999 (for fusion) to report SPECT/CT on parathyroid imaging exams be discontinued and the new code 78072 be used instead?

Answer: Yes. Discontinue the reporting of code 78999 (for fusion) for claims with a date of service of January 1, 2013, and beyond, if you are performing SPECT/CT for parathy-roid imaging. Report only the new code 78072. Code 78072 captures the work of the fusion for anatomical localization with SPECT and CT for parathyroid imaging.

Medicine: Neurology and Neuromuscular ProceduresQuestion: Can range of motion (95851) and manual muscle testing (95831-95833) be reported on the same day?

Answer: Yes. Manual muscle testing and range of motion testing are designated as separate procedures; therefore, they may be reported on the same day, if performed.u


17screening images are evaluated to determine if there are any findings that require additional evaluation with diagnostic mammography. CAD is activated. Any areas CAD has flagged for additional consideration are evalu-ated. The areas on current examination are compared with any older examinations. It is determined whether there is a need to recall the patient for diagnostic mammography for additional evaluation of any areas flagged by CAD. An examination report is dictated. In states with dense breast–notification legislation, required verbiage informing the referring provider that his or her patient has dense breast tissue is included.u

Clinical Example (77067)A 46-year-old asymptomatic female presents for her annual screening mammogram with CAD.

Description of Procedure (77067)It is determined whether the screening mammographic images are of adequate quality for interpretation or whether any images require repeating due to motion unsharpness, inadequate positioning, or artifacts. The current screening examinations are compared with any older examinations to evaluate for stability or interval change. The current

Reporting Mammography Services, continued from page 15

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