ED Coding and Reimbursement Alert

Hint: Be ready for big changes to chest x-ray coding.

Just as you're prepping your coding systems for the new ICD-10 codes that took effect Oct. 1, it's time to get ready for another fresh set of codes - this time from CPT^®. The following breakdown can help you prepare for the changes that the AMA has set forth for ED coders when the calendar turns to 2018.

1. Overhaul to the Chest X-Ray Section

When CMS released its 2018 proposed Medicare Physician Fee Schedule, coders may have noticed that it listed four new chest x-ray codes. However, the proposal didn't indicate whether these new codes would replace existing ones or supplement then. Now, with the release of CPT^® 2018, it's clear that the new codes will replace the x-ray codes that many ED coders have committed to memory. The new chest x-ray codes are as follows:

• 71045 (Radiologic examination, chest; single view)
• 71046 (Radiologic examination, chest; 2 views)
• 71047 (Radiologic examination, chest; 3 views)
• 71048 (Radiologic examination, chest; 4 or more views)

Meanwhile, CPT^® has eliminated all of the existing chest X-ray codes from the 2018 manual. Everything in the 71010-71035 range will be deleted from CPT^® effective Jan. 1.

"It seems that the codes are being simplified based on the number of views in total, rather than the type of view (e.g., frontal and lateral [71020] vs lateral decubitus [71035]) or method (e.g., frontal and lateral with oblique projections [71022])," says Carol Pohlig BSN, RN, CPC, ACS,  senior coding and education specialist at the Hospital of the University of Pennsylvania. "It will be interesting how they adjust the value to accommodate the simple and complex services being represented by the same code set," she said.

2. Updates to Abdominal X-Ray Codes

Much as CPT^® streamlined the chest x-ray code section, the same type of changes will happen to abdominal x-rays, with the following three new codes debuting in this section:

• 74018 (Radiologic examination, abdomen; 1 view)
• 74019 (Radiologic examination, abdomen; 2 views)
• 74021 (Radiologic examination, abdomen; 3 or more views)

These new codes will replace the previous abdominal x-ray codes 74000-74022, which will be deleted in the New Year. The updated code list suggests that coders will no longer have to worry about which specific views were taken (such as decubitus, anteroposterior, etc.) and instead will just focus on how many views were taken in total.

3. Ultrasound of Extremities Descriptors Expand

The preamble to the extremities codes in CPT^®'s ultrasound section has been expanded significantly. For instance, the notes now indicate that 76881 (New descriptor as of Jan. 1: Ultrasound, complete joint [i.e., joint space and periarticular soft-tissue structures], real-time with image documentation) "requires ultrasound examination of all of the following joint elements: Joint space (e.g., effusion), peri-articular soft tissue structures that surround the joint (i.e., muscles, tendons, other soft-tissue structures), and any identifiable abnormality."

To report this code, you must also permanently record the images and maintain a written report with a description of each element visualized "or reason that an element(s) could not be visualized (e.g., absent secondary to surgery or trauma)," CPT^® says.

If you don't perform the elements required by CPT^®, you should instead report the "limited" code, 76882 (New descriptor effective Jan. 1: Ultrasound, limited, joint or other nonvascular extremity structure(s) (eg, joint space, peri-articular tendon[s], muscle[s], nerve[s], other soft tissue structure[s], or soft tissue mass[es]), real-time with image documentation).

To submit 76882, CPT^® requires a limited evaluation including "assessment of a specific anatomic structure(s) (e.g., joint space only [effusion] or tendon, muscle, and/or other soft-tissue structure[s] that surround the joint) that does not assess all of the required elements included in 76881," the manual will now state.

4. Update Lab Test, Needle Introduction Codes

CPT^® has also debuted two new lab codes that could impact ED coders, as follows:

• 87634 (Infectious agent detection by nucleic acid (DNA or RNA); respiratory syncytial virus, amplified probe technique)
• 87662 (Infectious agent detection by nucleic acid (DNA or RNA); Zika virus, amplified probe technique)

In addition, the latest version of CPT^® will update the descriptor for 36140 (Introduction of needle or intracatheter, upper or lower extremity artery). Although the code itself will remain the same, the new verbiage specifies that the code refers to either the upper or lower extremity artery. In the past, the descriptor simply referred to "extremity artery."

5. Subtle Language Change to Observation Codes 99217-99220

You have to look closely to notice, but the preamble to the "Initial Observation Care, New and Established Patient" section of CPT^® and the full code descriptors for 99217-99220 have the words "outpatient hospital" inserted before the term "observation status." For example, the passages now read asfollows:

"The following codes are used to report the encounter(s) by the supervising physician or other qualified health care professional with the patient when designated as outpatient hospital 'observation status.'"

This appears to indicate observation services are only allowed in the hospital setting, whereas the presumption in the past was that observation was a "status" and not a defined place. That status is now limited to the outpatient hospital setting. This should not be a concern for hospital-based EDs, but it could be a concern for freestanding emergency centers if they are deemed not to be outpatient hospitals.

Keep an eye on Emergency Department Coding Alert as new directives are issued that shed additional light on how to report the new codes for 2018.

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