General Surgery Coding Alert

G-tube procedure codes also undergo extensive revisions

While numerous small tweaks and a few code "renumberings" make up the bulk of CPT changes affecting general surgery practices in the new year, you will also find a number of important, all-new codes for vascular grafts and abdominal tumor excisions, among others. Begin familiarizing yourself with all the changes now so you can transition to the new year without missing a beat -- or filing an outdated claim.

The lung/pleura surgery portion of CPT gets five new codes -- but they-re not really new, says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, CPC-OBGYN, CPC-CARDIO, manager of compliance education for the University of Washington Physicians (UWP) and Children's University Medical Group (CUMG) Compliance Program. CPT 2008 simply deletes five codes and replaces them with different codes that have almost exactly the same descriptors:

Descriptors for 32422 and 32551 include slightly different language than their predecessors 32002 and 32020 -- specifically, they include the phrase "includes water seal ... when performed," instead of "with or without water seal" -- but appropriate use of all of the "new" codes will mirror exactly that of previous codes 32000-32020.

You may find yourself accessing several new grafting codes if your general surgeon specializes in vascular surgery.

First among these, 33864 (Ascending aorta graft, with cardiopulmonary bypass with valve suspension, with coronary reconstruction and valve-sparing aortic annulus remodeling [e.g., David procedure, Yacoub procedure]), describes a cutting-edge aortic valve graft procedure known as the Tirone David procedure or the Yacoub procedure. This involves an ascending aorta graft with a cardiopulmonary bypass for valve suspension. It also includes coronary reconstruction and "valve-sparing aortic annulus remodeling." Because the aortic valve is such a complex structure, no valve prosthesis can duplicate its function. Surgeons have developed procedures that either spare the aortic valve or replace it with autologous tissue.

CPT 2008 also adds 35523 (Bypass graft, with vein; brachial-ulnar or -radial), which describes a graft not previously given a code.

A few additional, non-grafting cardiac codes may affect your practice. For instance, if your surgeon places a wireless physiologic sensor in the aneurismal sac during an endovascular repair, you-ll have a new code to report the procedure: +34806, Transcatheter placement of wireless physiologic sensor in aneurysmal sac during endovascular repair, including radiological supervision and interpretation, instrument calibration, and collection of pressure data. The service includes radiological supervision and interpretation, instrument calibration, and collection of pressure data. Code 34806 replaces the now-deleted Category III code +0153T.

Choose blood collection by device: When your doctor collects a blood specimen, you-ll have two new codes: 36591 covers collection from a completely implantable venous access device (VAD), and 36592 covers collection from an established central or peripheral venous catheter, which is "not otherwise specified." These codes will replace the now-deleted 36540.

Declotting varies from collection: For declotting of a VAD or catheter, rather than blood collection, you should now report 36593 (Declotting by thrombolytic agent of implanted vascular access device or catheter), which replaces 36550 for 2008.

CPT 2008 deletes 43750 (Percutaneous placement of gastrostomy tube) and replaces it with three new codes that more precisely describe insertion of gastrostomy (49440), duodenostomy or jejunostomy (49441), or cecostomy or other colonic (49442) tubes:

Guidance is included: All of the above insertions take place "under fluoroscopic guidance including contrast injection(s), image documentation and report," and you therefore would not report this service separately, Bucknam notes. To drive the point home, CPT 2008 deletes 74350, which you would have used previously for fluoroscopic guidance for tube placement.

CPT 2008 also introduces three new codes for gastrostomy tube maintenance.

A surgeon might use these codes if the tubes weren't placed endoscopically," says Kathleen A. Mueller, RN, CPC, CCS-P, CMSCS, a healthcare consultant in Lenzburg, Ill.

Imaging included in replacements, too: As with insertion codes 49440-49442, replacement codes 49450-49452 include fluoroscopic guidance. To reflect this, the AMA has revised 75984 (Change of percutaneous tube or drainage catheter with contrast monitoring [e.g., genitourinary system, abscess], radiological supervision and interpretation) to remove reference to the gastro-intestinal system.

What about G tube with no imaging? You previously used 43760 for all G-tube changes. Now, you will use it only to report G-tube changes without imaging guidance. CPT 2008 changes the wording of gastrostomy tube change code 43760 to specify "change of gastrostomy tube, percutaneous, without imaging or endoscopic guidance" [emphasis added].

Now, if your surgeon destroys an intra-abdominal tumor, cyst or endometrioma, you-ll have to be sure that her documentation specifies size, says M. Trayser Dunaway, MD, a surgeon, coding educator and healthcare consultant in Camden, S.C. Several new, size-specific codes will replace 49200-49201, which merely divided these procedures into "regular" and "extensive" excision or destruction:

Application will be easy: If the largest tumor the surgeon removes or destroys is 5 cm or less in diameter, then you code 49203. If the largest tumor is between 5.1 cm and 10 cm in diameter, code 49204. If the largest of the tumors is bigger than 10.0 cm in diameter, you-ll report 49205.

The descriptor for mesh-placement code +49568 (Implantation of mesh or other prosthesis for incisional or ventral hernia repair or mesh for closure of debridement for necrotizing soft tissue infection [list separately in addition to code for the incisional or ventral hernia repair]) now includes language clarifying that you may report this code for the placement of mesh for debridement of necrotizing soft tissue infection.

You-ll also still use 49568 for mesh placement for ventral or incisional hernia repair, Dunaway says.

Keep watching: In the coming months, General Surgery Coding Alert will cover the most significant CPT changes in greater depth, and keep you up-to-date on how payers are responding to the new and revised codes.