1. Maya Turner, CPC Coding Eductor,
2019 Proposed CPT Updates
Maya Turner, CPC
Coding Eductor,

2. 2019 CPT “Proposed” Changes
Please note these updates presented today are proposed changes and the official changes related to 2019 will be introduced at the AMA symposium.
AMA’s official announcement of the proposed changes was published via the AMA Newsletter September 5, 2018.

3. Facility Based Services
CY 2019 Proposed
Payment Changes
Facility Based Services

4. CMS OPPS and ASC 2019 Proposed Changes – Provider Based Departments
Major Changes to include:
Site neutral payment policy for “certain” outpatient services furnished in off campus provider based departments. Changing the payment payment policy reflecting clinic based services or for outpatient drug services owned and/or operated by the facility. Resulting in significant payment reduction. (if finalized) IF? More like when..
Providers comment period to respond to these changes ended on September 24th.

5. CMS OPPS and ASC 2019 Proposed Changes – Covered Procedures List (CPL)
The ASC Covered Procedures List (CPL) is a list of covered surgical procedures that are payable by Medicare when furnished in an ASC
Under current policy, covered surgical procedures may include those described by certain Common Procedural Terminology (CPT) codes that are within the surgical code range or other types of codes that directly crosswalk or are clinically similar to CPT codes within the surgical code range.

6. CMS OPPS and ASC 2019 Proposed Changes – Covered Procedures List (CPL)
CMS is proposing to allow certain CPT codes outside of the surgical code range that directly crosswalk or are clinically similar to procedures within the CPT surgical code range to be included on the CPL and is proposing to add certain cardiovascular codes to the ASC CPL as a result.
Additionally, CMS is proposing to review all procedures added (within the past three years) to reassess recent experience with the procedures in the ASC and to determine whether such procedures should continue to be on the ASC CPL.

7. CMS OPPS and ASC 2019 Proposed Changes cont’d
Under the previously described proposed policy, payment rates for these services would be equal to the rates established under the physician fee schedule rather than the rates established under the OPPS

8. CMS OPPS and ASC 2019 Proposed Changes – Blood and Blood Components
CMS proposes to continue establishing separate payment rates for blood and blood products using a blood-specific cost-to-charge ratio (CCR) methodology
CMS proposes to continue to apply the blood-specific CCR methodology when calculating the costs of blood and blood products that appear on claims with services assigned to comprehensive APCs (C-APCs)

9. proposed 2019 cpt updates

10. Proposed 2019 CPT Changes Overview
The new current procedural terminology (CPT®) codes have been released with 335 code changes in 2019. 
There were changes made in all categories. The most impactful made to Evaluation and Management. CMS proposed changes would overhaul payment and documentation requirements.
There were also many code revisions with guideline, description and instructional note changes.  

11. EVALUATION AND management
2019 Payment Restructure and Documentation Proposed Changes

12. 2019 Evaluation and Management “Proposed” Payment Restructure
New Patient LOS “Proposed” Payment Changes
CMS proposed a similar structure for new patient codes , which would be reimbursed at $135, regardless of the level of service. For the sake of comparison, currently pays about $110, and nets $167. Under the proposal, level 1 codes would have a separate payment similar to the current rates.

13. 2019 Evaluation and Management “Proposed” Payment Restructure
Established Patient LOS Payment Changes
CMS seeks to create a single payment of $93 for established patient codes that would replace distinct pay rates for each of the four codes. That rate, in 2018 dollars, is roughly smack in the middle of payments for ($74) and ($109). The rate is significantly lower than level 5 code 99215, which pays $148 this year.

14. 2019 Evaluation and Management “Proposed” Documentation Restructure
Medical Necessity for LOS will be determined by Medical Decision Making OR Time spent
The first of the proposed changes is to allow providers to base E/M coding determinations on medical decision-making or time in addition to the current E/M coding guidelines from 1995 and 1997 that are primarily based on providers’ work and cognitive labor.

15. 2019 Evaluation and Management “Proposed” Additional Codes and other changes
Pay may be cut for same-day E/M visits, procedures
CMS proposes to apply a multiple-service payment adjustment when an E/M visit is reported the same day as a procedure, similar to the long-standing multiple-procedure payment reduction for surgical and some imaging services.
When an E/M is reported on the same date as a procedure, Medicare would reduce payment by 50% for the least expensive service provided. In most cases, it would be the E/M service

16. 2019 Evaluation and Management “Proposed” Additional Codes and other changes
CMS proposes add-on G codes for primary care
+GPC1X – Visit complexity inherent to E/M associated with primary medical care services that serve as the continuing focal point for all needed health care services list separately in addition to an established patient evaluation and management visit

17. 2019 Evaluation and Management “Proposed” Additional Codes and other changes
CMS proposes add-on G codes for Specialists
+GCG0X - Visit complexity inherent to evaluation and management associated with endocrinology, rheumatology, hematology/oncology, urology, neurology, obstetrics/gynecology, allergy/immunology, otolaryngology, cardiology, or interventional pain management-centered care CMS would assign 0.25 work RVUs to the code.

18. 2019 Evaluation and Management “Proposed” Additional Codes and other changes
CMS proposed G code for brief communication
GVCI1 - Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, NOT originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion

19. Evaluation and Management services
2019 Proposed CPT Updates
Evaluation and Management services

20. Evaluation and Management – Changes Overview
There are six new codes in the Evaluation and Management (E&M) section in CPT.
Guidelines were revised for Inter-professional Telephone/Internet/Electronic Health Record Consultations.

21. Evaluation and Management 99451 and 99452 – Electronic Record Assessment/Consultative Services
Inter-professional telephone/Internet/electronic health record assessment and management service provided by a consultative physician, including a written report to the patient’s treating/requesting physician or other qualified health care professional, 5 minutes or more of medical consultative time.
Consultative service lasting more than 5 minutes and requires only a written report to the requesting physician.
This was added recognizing that oral communications do not always occur between healthcare professionals and may facilitate consultative services in geographic areas with no specialists available.

22. Evaluation and Management 99453 and 99454 – Remote Physiologic Monitoring Services
99453 – Remote monitoring of physiological parameter(s) (e.g., weight, blood pressure, pulse oximetry respiratory flow rate, initial; set up, patient education on use of equipment
Remote monitoring of physiological parameter(s) (e.g., weight, blood pressure, pulse oximetry respiratory flow rate, initial; device(s) supply, with daily recording(s) or programmed alert(s) transmission, each 30 days.

23. Evaluation and Management 99457– Remote Physiologic Monitoring Services
Remote physiologic monitoring treatment management services, 20 minutes or more of clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month

24. 99491 – Chronic Care Management (Personally Performed by Provider)
When Services are personally performed by a physician or other qualified health care professional, at least 30 minutes of physician or other qualified health care professional time, per calendar month.
Major difference between this and the CCM services code is when the provider personally performs the difference in time would be 30 minutes. Compared to 20 minutes for clinical staff

25. 2019 Proposed CPT Updates
Surgery

26. Surgery/Procedure based services with Imaging Guidance – Guidelines
Surgery chapter guidelines contain a new section on imaging guidance reminding practices that radiology services must be properly documented even when imaging is an integral part of the service
In addition, the new guidance warns practices that non-image guided tracking or localization – such as radar – should not be reported with radiology codes. “Imaging guidance should only be reported when an imaging modality (eg, radiography, fluoroscopy, ultrasonography, magnetic resonance imaging, computed tomography, or nuclear medicine) is used and is appropriately documented,”

27. Surgery Updates – Integumentary Procedures
Understand detailed guidance for fine needle aspiration biopsy as there have been description revisions for:
(Fine needle aspiration biopsy; without imaging guidance) will be revised to state “Fine needle aspiration biopsy; without imaging guidance; first lesion.
(Each additional lesion [List separately in addition to code for primary procedure]

28. Surgery Updates – Integumentary Procedures cont’d
When a provider performs multiple biopsies with different imaging methods, report the appropriate primary code – and add-on codes, if appropriate – with modifier 59 (Distinct procedural service).
If a provider performs FNAB and CNB on the same lesion, don’t report the image guidance for the CNB.

29. Surgery Updates – Musculoskeletal
Look for imaging code guidance with new knee arthrography code.
27370 Injection of contrast for knee arthrography has been deleted.
Replaced with (Injection procedure for contrast knee arthrography or contrast enhanced CT/MRI knee arthrography. Further clarification provided within the chapter preface and parenthetical guidelines

30. Surgery Updates – Musculoskeletal
Additional updates include:
Fluoroscopic needle guidance
Computed tomography, lower extremity; with contrast material[s]) or (…; without contrast material, followed by contrast material[s] and further sections)
Fluoroscopic needle guidance is used for an enhanced magnetic resonance arthrography use the needle guidance code (in addition to needle code)
(…; without contrast material, followed by contrast material[s] and further sequences).

31. Surgery Updates – Musculoskeletal
Additional updates include:
Fluoroscopic needle guidance
Computed tomography, lower extremity; with contrast material[s]) or (…; without contrast material, followed by contrast material[s] and further sections)
Fluoroscopic needle guidance is used for an enhanced magnetic resonance arthrography use the needle guidance code (in addition to needle code)
(…; without contrast material, followed by contrast material[s] and further sequences).
Radiologic Examination knee arthrography, supervision and interpretation

32. Surgery Updates – Cardiovascular
Pacemaker and Defibrillator Updates regarding leadless pacemakers. These new guidelines are also found in the section of the manual.
Category III codes have now been put in function in Category II they are:
0357T-0391T are deleted and replaced with Transcatheter insertion or replacement of permanent leadless pacemaker, right ventricular, including imaging guidance [eg, fluoroscopy, venous ultrasound, ventriculography, femoral venography] and device evaluation [eg, interrogation or programming], when performed
33275 – (Transcatheter removal of permanent leadless pacemaker, right ventricular)

33. Surgery Updates – Cardiovascular cont’d
New guidelines state that insertion of a catheter into the right ventricle is included in the insertion, replacement or removal of a leadless pacemaker system. In addition, right heart catheterization codes
Right heart catheterization codes 93451, 93453, 93456, 93457, 93460, and should NOT be reported with the insertion or removal codes unless the right heart catheterization treats a condition that is “distinct from the leadless pacemaker procedure.” And when a system is removed and replaced during the same session, report 33274

34. Surgery Updates – Cardiovascular cont’d
Central venous access revisions – The changes to the peripherally inserted central catheter (PICC) codes are the stars of this section, but don’t overlook guidance under the central venous access procedures subsection. The new manual now states that it is appropriate to code a PICC line when a saphenous vein is the insertion site.

35. Surgery Updates – Cardiovascular cont’d
There are also more detailed guidelines for reporting flouroscopic central venous catheter code and 76937
revised description now includes image guidance new (Replacement, complete, of a peripherally inserted central venous catheter [PICC], without subcutaneous port or pump, through same venous access, including all imaging guidance, image documentation, and all associated radiological supervision and interpretation required to perform the replacement)

36. Surgery Updates – Cardiovascular cont’d
(Insertion of peripherally inserted central venous catheter [PICC], without subcutaneous port or pump, including all imaging guidance, image documentation, and all associated radiological supervision and interpretation required to perform the insertion; younger than 5 years of age)
(…; age 5 years or older)
Note: Chest X-ray codes ( ) or other imaging services to document the final catheter tip position are bundled into and However, when the provider uses imaging but does not confirm the tip’s location, the practice should append modifier 52 (Reduced services) with the code.

37. 2019 Proposed CPT Updates
Radiology

38. Radiology Updates – Guidelines
The latest CPT manual updated the supervision and interpretation section of the chapter’s guidelines to clarify the information providers should capture – and auditors will expect to see – when radiology services are performed.
According to the supervision and interpretation, imaging guidance section, all imaging guidance codes require image documentation in the patient chart and a description of the image guidance in the procedure note.

39. Radiology Updates – Guidelines Cont’d
Radiological supervision and interpretation (RS & I) documentation must include documentation in the patient’s “permanent record” and a procedure or separate image report “that includes written documentation of interpretive findings of information contained in the images and radiologic supervision of the service.”

40. 2019 Proposed CPT Updates
Medicine

41. Medicine – Vaccination Updates
Influenza virus vaccine quadrivalent [IIV4], inactivated, adjuvanted, preservative free, 0.25mL dosage, for intramuscular use)

42. Medicine – Behavioral Health Updates
Overall changes make it easier to report services. Including behavioral, psychological testing as well as neuropsychological testing.
For example, the central nervous system assessments/tests section of the medicine chapter clarifies that a psychological evaluation test may include “emotional and interpersonal functioning, intellectual function, thought processes, personality, and psychopathology.” By comparison, a neurobehavioral status examination could include “acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities

43. Medicine – Behavioral Health
96130 – Psychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member[s] or caregiver[s], when performed; first hour)
– For each additional hour

44. Medicine – Behavioral Health
(Psychological or neuropsychological test administration and scoring by physician or other
qualified health care professional, two or more tests, any method; first 30 minutes)
(…; each additional 30 minutes [List separately in addition to code for primary procedure])
(… by technician, two or more tests, any method; first 30 minutes)
(…; each additional 30 minutes [List separately in addition to code for primary procedure])

45. Medicine – Behavioral Health
96146 – (Psychological or neuropsychological test administration, with single automated, standardized instrument via electronic platform, with automated result only).

46. Medicine – Behavioral Health
97151 – (Behavior identification assessment, administered by a physician or other qualified health care professional, each 15 minutes of the physician’s or other qualified health care professional’s time face to face with patient and/or guardian[s]/caregiver[s] administering assessments and discussing findings and recommendations, and non-face-to-face analyzing past data, scoring/interpreting the assessment, and preparing the report/treatment plan) The code family also includes a supporting assessment code.
provider working under the direction of a physician in a supporting capacity.

47. Medicine – Behavioral Health
which “describe services that address specific treatment targets and goals based on results of previous assessments”
central nervous system assessments/tests

48. Questions???

49. References