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General Surgery Coding Alert

Be in the Know for 2003:

CPT Adds More New Codes, Greater Specificity

Published on Sat Feb 01, 2003

Along with the important changes covered last month, CPT 2003 has added or replaced dozens of codes to improve reporting specificity. These codes describe procedures as diverse as stent placement, apheresis, bone marrow transplants and more, and in some cases will greatly simplify surgeons' and coders' tasks.

More Precision for Venipuncture

Previously, a single code (36415) described routine venipuncture. For 2003, CPT revises 36415* (Collection of venous blood by venipuncture), removing the words "finger/heel/ear stick" (the procedure now includes only collection of blood via a needle through a vein) and adds 36416 (Collection of capillary blood specimen [e.g., finger, heel, ear stick]) to describe specimens acquired through a simple finger, heel or ear stick.

This change may be of special consequence for Medicare (and some private) payers. Because Medicare does not pay for finger/heel/ear sticks, it created its own venipuncture code (G0001) for use in place of 36415, which previously included such sticks. "Now that the AMA differentiates venipuncture from finger, heal and ear sticks, my feeling is that Medicare will drop G0001 and follow CPT," says Kathy Pride, CPC, CCS-P, HIM applications specialist with QuadraMed, which is based in San Rafael, Calif. Watch General Surgery Coding Alert for more information on this topic as it becomes available.

An Explosion of Apheresis Codes

For 2003, CPT deletes 36520 and 36521, which described apheresis (removing a specific component from the blood and returning it to the donor), and replaces them with six new codes:

  • 36511 Therapeutic apheresis; for white blood cells
  • 36512 for red blood cells
  • 36513 for platelets
  • 36514 for plasma pheresis
  • 36515 with extracorporeal immunoadsorption and plasma reinfusion
  • 36516 with extracorporeal selective adsorption or selective filtration and plasma reinfusion.

    As explained by the AMA's CPT Changes 2003: An Insider's View, "36520 and 36521 described outdated techniques that were no longer widely used. The new series of CPT codes reflects the current clinical practice and a more specific listing of the various components of the present clinical procedure," thus allowing for more accuracy when tracking the procedural type and frequency. According to CPT Changes, "These procedures may be performed under emergency conditions and may be associated with allergic reactions or other complications requiring physician intervention."

    Long-Needed Removal of Obstruction Codes Arrive

    A welcome addition to CPT 2003 are codes to describe removal of obstructive material from central venous devices (for example, fibrin at the distal end of the device or within the lumen), along with codes for the associated imaging procedures:

  • 36536 Mechanical removal of pericatheter obstructive material (e.g., fibrin sheath) from central venous device via separate venous access
  • 75901 Mechanical removal of pericatheter obstructive material (e.g., fibrin sheath) from central venous device via separate venous access, radiologic supervision and interpretation
  • 36537 Mechanical removal of intraluminal (intracatheter) obstructive material from central venous device through device lumen
  • 75902 Mechanical removal of intraluminal (intracatheter) obstructive material from central venous device through device lumen, radiologic supervision and interpretation.

    "Treatment options include stripping the fibrin sheath from/about the existing catheter by use of either a transcatheter snare or balloon under imaging guidance, or alternatively, clearing the intraluminal obstructive material with a guidewire, brush or other mechanical device under imaging guidance," CPT Changes explains.

    Prior to CPT 2003, there was wide dissent among coders and physicians about whether to use a code for retrieval of foreign body for such procedures, says Cindy Parman, CPC, CPC-H, RCC, co-owner of Coding Strategies Inc., an Atlanta-based firm. Some surgeons argued against the foreign-body codes because a fibrin sheath is a natural outcome of catheterization rather than foreign body. "With these new codes," Parman says, "we have a clear choice when reporting these procedures."

    Welcome 'All-Inclusive'TIPS Codes

    Two new codes will greatly simplify coding for transvenous intrahepatic portosystemic shunt(s), or TIPS, by including all component services (such as venous access, catheterization, image guidance, etc.) in the procedural descriptor:

  • 37182 Insertion of transvenous intrahepatic portosystemic shunt(s) (TIPS) (includes venous access, hepatic and portal vein catheterization, portography with hemodynamic evaluation, intrahepatic tract formation/dilatation, stent placement and all associated imaging guidance and documentation)
  • 37183 Revision of transvenous intrahepatic portosystemic shunt(s) (TIPS) (includes venous access, hepatic and portal vein catheterization, portography with hemodynamic evaluation, intrahepatic tract recanulization/dilatation, stent placement and all associated imaging guidance and documentation).

    Because the descriptors include the associated imaging guidance, you may not report imaging services 75885 or 75887 with 37182/37183.

    In addition, CPT 2003 adds a cross reference to 37182 to refer surgeons to revised code 37140 (Venous anastomosis, open; portocaval) for an open (rather than percutaneous) procedure.

    More Endoscopy Codes for Lower GI

    In past years, upper GI endoscopies were the only gastrointestinal endoscopies to include dilation procedures, leaving physicians to use an unlisted-procedure code to report lower GI endoscopies of the same type. For 2003, CPT adds dilation codes to the colonoscopy and sigmoidoscopy series:

  • 45340 Sigmoidoscopy, flexible; with dilation by balloon, 1 or more strictures
  • 45386 Colonoscopy, flexible, proximal to splenic flexure; with dilation by balloon, 1 or more strictures.

    According to CPT, you should not report 45340 with 45345, or 45386 with 45387 because these stent placement codes include predilation. In addition, because the code descriptors specify "1 or more strictures" you may report 45340/45386 only once per session regardless of the number of strictures dilated.

    Endoscopy Codes Add Injections

    CPT 2003 includes four new codes to describe endoscopic gastrointestinal (GI) procedures with associated submucosal injections:

  • 43201 Esophagoscopy, rigid or flexible; with directed submucosal injection(s), any substance
  • 43236 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with directed submucosal injection(s), any substance
  • 45335 Sigmoidoscopy, flexible; with directed submucosal injections(s), any substance
  • 45381 Colonoscopy, flexible, proximal to splenic flexure; with directed submucosal injection(s), any substance.

    Report the above codes only once regardless of the number of injections the surgeon administers. Substances injected could include India ink (to mark a lesion for removal, for example), botulinum toxin, saline or corticosteroid solutions.

    Endoscopies with submucosal injections are more difficult and time-consuming and involve greater risk than other endoscopies, but CPT contained no codes to describe such procedures prior to 2003. Further, CPT bundled injection codes 90780-90784 into many of the GI endoscopy procedures. To receive additional reimbursement, physicians had to report an unlisted-procedure code or use the "base" endoscopy code and append modifier -22 (Unusual procedural services), says Linda Parks, MA, CPC, CCP, lead coder at Atlanta Gastroenterology Associates. Even with appropriate documentation, payers delayed reimbursement, which was often inappropriately low, Parks says. "Hopefully," she says, "the new codes will end any delay and stop physicians from having to send extra paperwork."

    CPT 2003 also includes cross references instructing physicians and coders to use 43204 or 43243 rather than 43201 or 43236, respectively, when performing injection sclerosis of esophageal and/or gastric varices.

    Access New Catheter Code

    New code 49419 (Insertion of intraperitoneal cannula or catheter, with subcutaneous reservoir, permanent [i.e., totally implantable]) describes insertion of a permanent indwelling, totally implantable catheter without external access ports (for chemotherapy administration in women with ovarian or primary peritoneal cancer, for instance). The procedure requires an incision and the creation of a pocket for the reservoir. For removal or revision, CPT instructs you to use 49422 (Removal of permanent intraperitoneal cannula or catheter).

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