2019 Interventional Radiology Coding Update and Hot Topic Procedures by Panacea Healthcare Solutions

2019 Interventional Radiology Coding Update and Hot Topic Procedures Presented by Jeff Majchrzak, BA, RCC, CIRCC May 15, 2019

Disclaimer ▪

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Panacea Healthcare Solutions, Inc. has prepared this seminar using official Centers for Medicare and Medicaid Services (CMS) documents and other pertinent regulatory and industry resources. It is designed to provide accurate and authoritative information on the subject matter. Every reasonable effort has been made to ensure its accuracy. Nevertheless, the ultimate responsibility for correct use of the coding system and the publication lies with the user. Panacea Healthcare Solutions, Inc., its employees, agents and staff make no representation, warranty or guarantee that this information is error-free or that the use of this material will prevent differences of opinion or disputes with payers. The company will bear no responsibility or liability for the results or consequences of the use of this material. The publication is provided “as is” without warranty of any kind, either expressed or implied, including, but not limited to, implied warranties or merchantability and fitness for a particular purpose. The information presented is based on the experience and interpretation of the publisher. Though all of the information has been carefully researched and checked for accuracy and completeness, the publisher does not accept any responsibility or liability with regard to errors, omissions, misuse or misinterpretation. Current Procedural Terminology (CPT ®) is copyright 2018 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. Copyright © 2019 by Panacea Healthcare Solutions, Inc. All rights reserved. • No part of this presentation may be reproduced in any form whatsoever without written permission from the publisher. • Published by Panacea Healthcare Solutions, Inc., 444 Cedar Street, Suite 920, St. Paul, MN 55101.

Our Presenter Jeff Majchrzak, BA, RCC, CIRCC VP, Radiology & Cardiology Services Panacea, A Career Step Company Consultant, Author, Speaker

Over 300 hospitals and radiology practices nationwide have benefited from Jeff’s 20+ years of experience in radiology, nuclear medicine and administration. Jeff is the technical editor and author for several publications, in addition to the test for AAPC’s Certified Interventional Radiology Cardiovascular Coder (CIRCC) credential. © 2019 Panacea Healthcare Solutions, Inc. | 3

2019 CPT Errata and Technical Corrections Errata: Most recent entries added to Errata and Technical Corrections - CPT® 2019 ▪ Revision of codes in the parenthetical notes following codes 20933-20934. (E) ▪ Revision of parenthetical note following codes 32601, 32604. (E) • ▪ Revision of parenthetical notes following codes 34714, 34716, 34833. (T) ▪ Revision of guidelines for PICC line procedures. (T) ▪ Addition of parenthetical note following code 90847. (T) ▪ Revision of Health and Behavior Assessment/Intervention guidelines. (T) ▪ Revision of name of Appendix O. (T) ▪ Revision of codes in the Index under the “Repair” heading for “Malunion or Nonunion”, “Radius” and “Ulna”. (E) ▪ Revision of a code in the Index under the “Ulna” heading for “Malunion or Nonunion, Repair” in the Index. (E) ▪ Revise the Remote Physiologic Monitoring Treatment Management Services guidelines. (E) © 2019 Panacea Healthcare Solutions, Inc. | 4

2019 CPT Errata and Technical Corrections Errata: Previous entries added to Errata and Technical Corrections - CPT® 2019 ▪ Revise parenthetical note following code 99483. (T) ▪ Revise parenthetical note following code 15879. (T) ▪ Revise parenthetical note preceding code 20500. (T) ▪ Revise two parenthetical notes following code 20926. (T) ▪ Editorially revise code descriptors for codes 77061, 77062. (T) ▪ Revise symbol in code descriptors for codes 77402, 77407, 77412. (E) ▪ Revise full gene name for Fibrillin1 in the Molecular Pathology Gene Table. (E) ▪ Revise parenthetical notes following codes 97153, 97155. (T) ▪ Revise medium code descriptor for code 93296. (E)

2019 CPT Errata and Technical Corrections Errata: ▪ This info can be found at the following site: https://www.ama-assn.org/system/files/2019-03/cpt-correctionserrata-2019.pdf

2019 Introductory Language Change ▪ For 2019, there is new language in CPT referencing imaging guidance. This information appears in both the Surgery and Medicine sections of CPT. Verbatim: ▪ Imaging Guidance • When imaging guidance or imaging supervision and interpretation is included in a surgical procedure, guidelines for image documentation and report, included in the guidelines for Radiology (including Nuclear Medicine and Diagnostic Ultrasound) will apply. Imaging guidance should not be reported for use of a non-image guided tracking or localization system (e.g., radar signals, electromagnetic signals). Imaging guidance should only be reported when an imaging modality (e.g., radiography, fluoroscopy, ultrasonography, magnetic resonance imaging, computed tomography, or nuclear medicine) is used and is appropriately documented.

Fine Needle Aspiration (FNA) Biopsy ▪ 1 deleted code (10002) ▪ 1 revised code (10021) ▪ 9 added codes ▪ There are two codes describing this service being performed without imaging guidance. ▪ The codes and descriptions are as follows: • 10021 Fine needle aspiration biopsy, without imaging guidance; first lesion • +10004 Fine needle aspiration, without imaging guidance; each additional lesion (list separately in addition to code for primary procedure)

Fine Needle Aspiration (FNA) Biopsy ▪ There are 8 codes describing modality-specific guidance for Fine Needle Aspiration biopsy as well. ▪ Each choice has two options: 1. First lesion 2. Each additional lesion

Fine Needle Aspiration (FNA) Biopsy ▪ The modalities, codes and descriptions are as follows: Ultrasound ▪ 10005 Fine needle aspiration biopsy, including ultrasound guidance; first lesion ▪ +10006 Fine needle aspiration biopsy, including ultrasound guidance; each additional lesion (list separately in addition to code for primary procedure)

Fine Needle Aspiration (FNA) Biopsy Fluoroscopy ▪ 10007 Fine needle aspiration biopsy, including fluoroscopic guidance; first lesion ▪ +10008 Fine needle aspiration biopsy, including fluoroscopic guidance; each additional lesion (list separately in addition to code for primary procedure)

Fine Needle Aspiration (FNA) Biopsy CT ▪ 10009 Fine needle aspiration biopsy, including CT guidance; first lesion ▪ +10010 Fine needle aspiration biopsy, including CT guidance; each additional lesion (list separately in addition to code for primary procedure)

Fine Needle Aspiration (FNA) Biopsy MR ▪ 10011 Fine needle aspiration biopsy, including MR guidance; first lesion ▪ +10012 Fine needle aspiration biopsy, including MR guidance; each additional lesion (list separately in addition to code for primary procedure)

▪ Each code is used once per lesion, not per pass through a lesion.

Fine Needle Aspiration (FNA) Biopsy Question – ▪ What is a Fine Needle Aspiration (FNA) biopsy? Answer – ▪ When material in an area of interest is aspirated with a fine needle and cells are studied/examined cytologically (Cytological).

Fine Needle Aspiration (FNA) Biopsy Question – ▪ How is this different than a core needle biopsy? Answer – ▪ This procedure is most often performed with a larger bore needle to allow gathering of a core amount of tissue and this (tissue) is now evaluated histologically. (Histopathologic)

Fine Needle Aspiration (FNA) Biopsy Question – ▪ How many times are codes submitted? Answer – ▪ Once per lesion sampled in a single session.

Fine Needle Aspiration (FNA) Biopsy Question – ▪ Can imaging guidance codes be reported separately with these codes? Answer – No. The eight modality – specific codes are inclusive of the guidance used. ▪ When submitting code 10005 or +10006 for the same lesion sampled, do not also report 76942. ▪ When submitting code 10007 or +10008 for the same lesion sample do not also report 77002. ▪ When submitting code 10009 or +10010 for the same lesion sampled do not also report 77012. ▪ When submitting code 10011 or +10012 for the same lesion sample do not also report 77021. © 2019 Panacea Healthcare Solutions, Inc. | 17

Fine Needle Aspiration (FNA) Biopsy Question – ▪ If an FNA biopsy is performed without imaging guidance, what codes are available for assignment? Answer – ▪ Two codes. Similar to modality-specific choices, there is one code for the first lesion sampled (10021) and a single add-on code (+10004) for each additional lesion sampled.

Fine Needle Aspiration (FNA) Biopsy Unilateral and bilateral lesions ▪ Only a single unit of any primary code (10021, 10005, 10007, 10009, 10011) may be used at a single session. ▪ This means when using the same modality, even if two lesions are studied in two different anatomic locations, only one of these procedures is assigned a primary code. Every lesion studied after that using the same (modality) type of guidance is assigned the add-on code.

Fine Needle Aspiration (FNA) Biopsy Question – ▪ Is it ever possible to assign two primary codes at the same session? Answer – ▪ Yes. When two separate lesions are sampled using two different types of modality-specific guidance, each lesion is assigned the modality-specific primary code. Any additional lesions studied using the same type of guidance would be described by the modality-specific add-on code.

Fine Needle Aspiration (FNA) Biopsy Example: ▪ FNA biopsy of a single lesion in the liver using ultrasonic guidance. Code Assigned: ▪ 10005

Fine Needle Aspiration (FNA) Biopsy FNA biopsy of two separate lesions in the liver, one in the right lobe and one in the left lobe using ultrasonic guidance. Codes assigned: ▪ 10005 ▪ +10006 ▪ Remember, only one primary code is ever assigned when at the same session more than one lesion sampled using the same modality-specific imaging guidance.

Fine Needle Aspiration (FNA) Biopsy FNA biopsy of right kidney and FNA biopsy of left lung using CT guidance. Codes assigned: ▪ 10009 ▪ +10010 ▪ Even though two separate organs are sampled, the same type of modality-specific guidance was used. It is never appropriate to use more than one unit of the same primary code for the same modality at the same session.

Fine Needle Aspiration (FNA) Biopsy FNA biopsy of thyroid using ultrasonic guidance. FNA biopsy of pancreas using CT guidance. Codes assigned: ▪ 10005 ▪ 10009 ▪ Each modality-specific primary guidance code may be assigned because two different types (modalities) of guidance were used.

Fine Needle Aspiration (FNA) Biopsy Using MR guidance, three FNA samples were acquired from the same lesion. Code assigned: ▪ 10011 ▪ Even though three samples were acquired, they were all from the same lesion. It is never appropriate to assign more than one code at the same session when multiple passes are made and multiple samples are acquired of the same lesion.

Fine Needle Aspiration (FNA) Biopsy Difference between CPT instructions and CMS instructions Consider the following: ▪ Unless clearly stated in CPT code descriptions, core needle biopsy does not include imaging guidance. ▪ As such, modality-specific guidance codes such as 76942 (ultrasound), 77002 (fluoro), 77012 (CT) or 77021 (MR) may be assigned in addition to core biopsy procedures in certain circumstances.

Fine Needle Aspiration (FNA) Biopsy Question – ▪ What if both FNA biopsy and core biopsy are performed at the same session on the same lesion using the same type of imaging guidance?

Answer – ▪ Per CPT, assign the modality-specific FNA biopsy code and the organ specific core biopsy code, but do not also assign a separate modality-specific guidance code that was used for the core biopsy.

Fine Needle Aspiration (FNA) Biopsy Example: ▪ At the same session, an ultrasound-guided FNA biopsy and an ultrasound-guided core biopsy of a single lesion are performed.

Codes assigned: ▪ 10005 ▪ 47000

Fine Needle Aspiration (FNA) Biopsy *Be aware that per 2019 CCI narrative instructions, this type of coding is not correct.

Per chapter 3, section L, # 12, CCI instructions have been revised for 2019 to read: â&#x2013;Ş 12. Fine needle aspiration (FNA) biopsies (CPT codes 1000410012, and 10021) shall not be reported with a biopsy procedure code for the same lesion. For example, an FNA specimen is usually examined for adequacy when the specimen is aspirated. If the specimen is adequate for diagnosis, it is not necessary to obtain an additional biopsy specimen. However, if the specimen is not adequate and another type of biopsy (e.g., needle, open) is subsequently performed at the same patient encounter, the physician shall report only one code, either the biopsy code or the FNA code. (CPT code 10022 was deleted January 1, 2019.)

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Fine Needle Aspiration (FNA) Biopsy Example: ▪ At the same session, FNA biopsy of liver using ultrasound guidance and core biopsy of lung using CT guidance. Codes assigned: ▪ 10005 ▪ 32405 ▪ 77012

▪ Since two different sites are sampled using two different types of modality-specific guidance, each code may be assigned. Closely monitor payor and CCI instructions when billing the same type of imaging guidance codes together (i.e., FNA and image-guided core biopsy). © 2019 Panacea Healthcare Solutions, Inc. | 30

Fine Needle Aspiration (FNA) Biopsy Example: ▪ Bilaterally, at the same session, using fluoroscopic guidance, two separate lesions in the same type of organ (kidney) were sampled using the same type of imaging guidance. One lesion was sampled using an FNA technique, the other using a core biopsy technique. Each lesion was separate and discrete. Codes assigned: ▪ 10007 ▪ 50200 ▪ 77002 ▪ As each lesion sampled is located in a different organ, both types of biopsy codes may be assigned. Additionally, even though each of these procedures are performed using fluoroscopic guidance, because they are in separate anatomic structures and not the same lesion, both may be coded. © 2019 Panacea Healthcare Solutions, Inc. | 31

Fine Needle Aspiration (FNA) Biopsy Other Thoughts – ▪ Remember these codes (10021, 10004-10012) are not specific to an anatomic site, but are specific to a particular imaging guidance modality and are reported per lesion studied. ▪ When an image-guided puncture of the location is performed of the soft tissue lesion and a drainage catheter was placed, this continues to be defined by CPT code 10030. ▪ When an image-guided puncture of a location is performed (with no placement of a catheter that is left in the patient at the termination of the procedure) fluid is withdrawn, but a true aspirational biopsy is not performed, continue to report the modality-specific guidance code and CPT code 10160. ▪ Code 10160 describes puncture aspiration of an abscess, hematoma, bulla or cyst. Code 10160 does not include imaging guidance. (See appropriate code based upon the type of guidance used [ultrasound 76942, Fluoro 77002, CT 77012, MR 77021). ▪ Throughout the CPT manual, numerous parentheticals are found after existing core needle biopsy code choices (i.e., 20206, 47000, 50200, etc.) referencing the reader to a FNA biopsy code if that is the service provided. Referred to your 2019 CPT manual for a complete listing of these options.

Injection for Knee Arthrography ▪ Deleted 27370 ▪ Added 27369 The new code and full description is as follows: ▪ 27369 Injection procedure for contrast knee arthrography or contrast enhanced CT/MRI knee arthrography

Injection for Knee Arthrography In 2018, CPT 27370 read as: ▪ 27370 Injection of contrast for knee arthrography Why was this change made? ▪ This change resulted in a more specific definition and now includes CT and MR as well in its description.

Injection for Knee Arthrography ▪ In addition to the code for the injection procedure, based upon the actual service performed, coding options could be as follows. CT arthrogram of knee ▪ CT with contrast ▪ CT without followed by with contrast

73701 73702

Injection for Knee Arthrography MR arthrogram of knee ▪ MRI of knee with contrast 73722 ▪ MRI of knee without followed by with contrast 73723

Injection for Knee Arthrography Fluoroscopic arthrogram of knee ▪ Fluoroscopic knee arthrography

73580

▪ As with the previous (2018) choice, when fluoroscopy is used to perform the injection into the knee followed by either CT or MRI of the knee, when documented, a code for the fluoroscopic guidance may also be used. For example: Fluoro- guided injection of knee followed by MRI of the knee with contrast Codes assigned: ▪ 77002 ▪ 27369 ▪ 73722 © 2019 Panacea Healthcare Solutions, Inc. | 37

Injection for Knee Arthrography Diagnostic CT of knee without contrast. This is followed by Fluoro-guided injection of knee. Next, CT scan of knee is performed (post intra-articular contrast injection). Codes assigned: ▪ 77002 ▪ 27369 ▪ 73703

Injection for Knee Arthrography Radiographic and fluoroscopic (R&F) arthrogram of knee. Codes assigned: ▪ 73580 ▪ 27369 ▪ In this scenario, do not charge separately for fluoroscopy when a fluoro-guided injection of the knee is done that is followed by a radiographic and fluoroscopic (R & F) arthrogram of the knee as S and I code 73580 is inclusive of fluoroscopy. ▪ Assigning code 77002 in addition to code 73580 would be incorrect and result in overpayment / double-billing for this portion of the study. © 2019 Panacea Healthcare Solutions, Inc. | 39

Injection for Knee Arthrography Question – ▪ How is CPT 27369 different than the "major joint" injection or aspiration codes.

Answer – ▪ CPT also provides two other codes that may be confused with code 27369. The codes are as follows: • 20610 Arthrocentesis, aspiration and/or injection, major joint or bursa (e.g., shoulder, hip, knee, subacromial bursa; without ultrasonic guidance • 20611 Arthrocentesis, aspiration and/or injection, major joint or bursa (e.g., shoulder, hip, knee, subacromial bursa; with ultrasonic guidance, with permanent recording and reporting

▪ The key difference between these codes is that the code 27369 is for injection of contrast material. If an injection is made into the knee of anything other than contrast, refer to code 20610 or 20611 depending upon whether ultrasound-guidance was used (20611) or not used (20610).

Central Venous Access Procedures ▪ Codes added 2 ▪ Codes deleted 0 ▪ Descriptions revised

Central Venous Access Procedures ▪ In the statement that describes what qualifies as a central venous access catheter or device, a subtle change was made. Relative to what a "peripherally inserted" catheter / device is, the words "saphenous vein entry" were added to increase the options that would correctly define a peripheral insertion. ▪ Regardless of where inserted from (i.e., centrally or peripherally) to qualify as a central venous access catheter or device, the tip of the catheter must end up / terminate in one of the following locations: 1. 2. 3. 4. 5. 6.

subclavian vein innominate/brachiocephalic vein superior vena cava (SVC) right atrium (right heart) iliac vein inferior vena cava (IVC)

Mid-line Catheter ▪ To this point, another important clarification in CPT 2019 was that of "what is a midline" catheter/device. This clarification likely will clear up what has been in the past somewhat confusing. ▪ As stated above, to qualify as a central venous access catheter or device, the tip of the catheter must terminate in one of the six locations previously defined. ▪ If the catheter does not and in one of those locations, it is not a central venous catheter. As such, narrative instructions in CPT 2019 state the following: ▪ "Midline catheters by definition terminate in the peripheral venous system. They are not central venous access devices and may not be reported as a PICC service. Midline catheter placement may be reported with 36400, 36405, 36406 or 36410. PICCs placed using magnetic guidance or any other guidance modality that does not include imaging or image documentation are reported with 36568 or 36569”.

Central Venous Access Procedures Question – ▪ Intent is to place a PICC. This cannot be done. The catheter is advanced only into a peripheral vein. Is this still coded as a PICC, but with modifier -52?

Answer – ▪ No, assign one of the codes from the 36400, 36406 or 36410 options. (I posed this question at the 2019 AMA CPT Code Symposium and the response was provided by the physician presenting this session).

Central Venous Access Procedures Codes and descriptions are as follows: ▪ 36400 Venipuncture, younger than age 3 years, necessitating the skill of the physician or other qualified healthcare professional, not to be used for routine venipuncture; femoral or jugular vein ▪ 36406 Venipuncture, younger than age 3 years, necessitating the skill of the physician or other qualified healthcare professional, not to be used for routine venipuncture; other vein ▪ 36410 Venipuncture, age 3 years or older, necessitating the skill of the physician or other qualified healthcare professional (separate procedure), for diagnostic or therapeutic purposes (not to be used for routine venipuncture)

Central Venous Access Procedures â&#x2013;Ş Introductory language for this section also states the following regarding image documentation: â&#x2013;Ş "When imaging guidance (e.g., ultrasound/fluoroscopy) is used for PICC placement or complete replacement repositioning, bundled service codes 36572, 36573, 36584 include all imaging necessary to complete procedure, image documentation (representative images from all modalities used are stored to the patient's permanent record), associated radiological supervision and interpretation, venography performed through the same venous puncture, and documentation of final central position of the catheter with imaging. Ultrasound guidance for PICC placement should include documentation of evaluation of the potential puncture sites, patency of the entry vein, and real-time ultrasound visualization of needle entry into the vein".

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Central Venous Access Procedures ▪ Generally, 2 new codes were added (36572, 36573) that bundle any/all imaging guidance used as part of the PICC line placement. ▪ Revisions were made to 2 codes which now define placement of a PICC without any imaging guidance (36568, 36569) ▪ The last code affected now defines a complete replacement of a PICC without a subcutaneous port or pump inclusive of imaging guidance (36584).

Central Venous Access Procedures The codes and full descriptions are as follows: ▪ 36568 Insertion of peripherally inserted central venous catheter (PICC) without subcutaneous port or pump, without imaging guidance; younger than 5 years of age ▪ 36569 Insertion of peripherally inserted central venous catheter (PICC) without subcutaneous port or pump, without imaging guidance; age 5 years or older

Central Venous Access Procedures ▪ Codes that parallel these (revisions for 2019 CPT) are those that include any/all imaging guidance. They are: • 36572 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 • 36573 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; age 5 years or older

Central Venous Access Procedures The final revision for CPT 2019 is defined as follows: â&#x2013;Ş 36584 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.

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Central Venous Access Procedures â&#x2013;Ş If the service defined by code 36584 is performed without imaging guidance, the unlisted procedure code of 37799 must be assigned. â&#x2013;Ş Since all these codes (36572, 36573 and 36584) now include imaging guidance, when used and documented, do not charge separately for this guidance (i.e., codes 76937 [ultrasound guidance for vascular access] or 77001 [fluoroscopic guidance for central venous access procedures]).

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Central Venous Access Procedures ▪ What about chest x-rays performed as part of the central venous access catheter placement? ▪ Per CPT, "Codes 71045, 71046, 71047, 71048 should not be reported for the purpose of documenting the final catheter position on the same day of service as 36572, 36573 or 36584. Codes 36572, 36573 and 36584 include confirmation of catheter tip location".

▪ Note that these three codes are new for CPT 2019 and are bundled to include "all imaging guidance".

Central Venous Access Procedures CPT 2019 also states the following: â&#x2013;Ş "The physician or other qualified healthcare professional reporting image-guided PICC insertion cannot report confirmation of catheter tip location separately (e.g., via x-ray, ultrasound). Report 36572, 36573, 36584 with modifier -52 when performed without confirmation catheter tip location".

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Central Venous Access Procedures Example: ▪ Image guidance (all documentation criteria met) used to place and advance PICC line but no statement made defining a final position using imaging. (Patient is 11 years of age),

Code assigned: ▪ 36573-52

Central Venous Access Procedures Note: ▪ The following information was provided as part of the handout material at the 2019 AMA CPT symposium and serves to illustrate possible scenarios regarding central venous access procedures and post-placement imaging. ▪ This information refers specifically to professional fee billing.

▪ Remember, under OPPS billing, the different number of providers does not affect hospital coding (Consider how this works for myelography when multiple providers are involved)

PICC Procedures: Examples Physician A places a PICC at bedside in an intensive care unit (ICU) patient using imaging guidance. Tip cannot be confirmed with ultrasound at bedside. A portable CXR is ordered by Physician A to confirm position. ▪ CXR is read by Physician B, who is in a different practice (different Tax ID Number [TIN]) • Physician A: 36573-52 • Physician B: 71045 ▪ CXR is read by Physician B, who is in the same group with the same TIN • Physician A: 36573-52 • Physician B: no code ▪ CXR is read by Physician B (same group, same TIN), but Physician A looks at the CXR and confirms that the tip is in the correct place • Physician a: 36573 • Physician B: no code ▪ CXR is read by Physician B (different group, different TIN), but Physician A looks at the CXR and confirms that the tip is in the correct place • Physician A: 36573-52 • Physician B: 71045 ▪ CXR is read by Physician A • Physician A: 36573 © 2019 Panacea Healthcare Solutions, Inc. | 56

PICC Procedures: Examples, continued Physician A places a PICC at bedside in an ICU patient without any imaging guidance. Tip cannot be confirmed at beside. A portable CXR is ordered by Physician A to confirm position. ▪ CXR is read by Physician B, who is in the same group with the same TIN • Physician A: 36569 • Physician B: 71045

▪ CXR is read by Physician B (same group, same TIN), but Physician A looks at the CXR and confirms that the tip is in the correct place • Physician A: 36569 • Physician B: 71045

▪ CXR is read by Physician B (different group, different TIN), but Physician A looks at the CXR and confirms that the tip is in the correct place • Physician A: 36569 • Physician B: 71045

Digestive System Stomach ▪ Codes added 2 ▪ Codes deleted 1 ▪ Descriptions revised

Digestive System ▪ Code 43760 was deleted. ▪ If a gastrostomy tube was replaced without image or endoscopic guidance, choose from one of the two new codes added in CPT 2019. ▪ Codes and full descriptions are as follows: • 43762 Replacement of gastrostomy tube, percutaneous, includes removal, when performed without imaging or endoscopic guidance; not requiring revision of gastrostomy tract • 43763 Replacement of gastrostomy tube, percutaneous, includes removal, when performed without imaging or endoscopic guidance; requiring revision of gastrostomy tract

Digestive System ▪ If a percutaneous gastrostomy tube replacement is done using fluoroscopic guidance, assign CPT code 49450 (assuming all other criteria for this code have also been met) ▪ As neither of these codes include imaging guidance (43762, 43763) it will be rare / unlikely that radiology departments will use them ▪ Think of "exception" as opposed to "rule" ▪ “What do you always do versus what you sometimes do”

Digestive System Question – ▪ What is the difference between the two codes? Answer – ▪ Code 43763 is assigned when a non-image guided gastrostomy tube exchange is performed that requires additional work than the typical procedure.

Urinary System ▪ Codes added 2 ▪ Codes deleted 1 ▪ Descriptions revised

▪ The narrative instructions have been updated for the section based upon the addition of two new codes in CPT 2019 for dilation of a new or existing GU tract for endourologic procedures.

Urinary System The codes and full description are as follows: ▪ 50436 Dilation of existing tract, percutaneous, for an endourologic procedure including imaging guidance (e.g., ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation, with post-procedure tube placement, when performed ▪ 50437 Dilation of existing tract, percutaneous, for an endourologic procedure including imaging guidance (e.g., ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation, with post-procedure tube placement, when performed including new access into the renal collecting system ▪ CPT code 50395 has been deleted for 2019 (but code 74485 is retained with the definition being revised). © 2019 Panacea Healthcare Solutions, Inc. | 63

Urinary System What happens in this procedure ▪ A tract is created percutaneously, through the body wall, into the kidney to allow passage of device into the kidney and ureter.

▪ Phrases that may assist coding staff in assigning the code/ identifying this procedure might be: • balloon dilator • serial dilators • sheath

Urinary System So what is the difference between the two codes and what's similar? ▪ Both codes include diagnostic ureterogram or nephrostogram (CPT 50430, 50431) ▪ Each code includes imaging guidance ▪ Each code includes S&I services (do not assign CPT 74485) ▪ Each code will be used to allow the GU tract to accommodate large sized instruments for the endourologic procedure (i.e., video scope) ▪ Both codes cannot be reported with actual stone removal codes (CPT 50080, 50081) ▪ Neither code should be reported for basic dilation and initial placement of a percutaneous nephrostomy (CPT 50432) or a nephroureteral catheter placement (CPT 50433) ▪ Neither code may be reported with percutaneous removal only (CPT 50384) or removal and replacement (CPT 50382) of an indwelling ureteral stent ▪ Neither code may be reported when a cystourethroscopy with insertion of ureteral guide wire through the kidney to establish a percutaneous nephrostomy, retrograde (CPT 52334) is performed

Urinary System ▪ Each of these codes (50436, 50437) refers to the dilation of the tract "into" the GU system for work "beyond" this point (i.e., dilated tract) ▪ Use CPT 50436 for dilation of an existing tract ▪ Use CPT 50437 for the dilation of a new tract that is created at that encounter