Oncology & Hematology Coding Alert

Find out what temporary code graduated to a regular CPT^® code.

You’ve likely been preparing for the E/M transformation about to hit as of January 1, 2021 — but you’ve got some oncology related changes to learn as well.

Get ready: For instance, you will have a new code for therapeutic drug assay, which is 80204 (Methotrexate), which should have a “big impact for oncology,” says Karen Pickering, RHIT, CCS, founder of ReviewMate and Senior Consultant for Pinnacle Enterprise Risk Consulting Services LLC.

Make 2021 your best year ever by learning and adapting to these five changes as soon as possible.

1. Adapt to the Major E/M Codes

Starting on Jan. 1, 2021, you will see major changes to the evaluation and management (E/M) office/outpatient visit codes, as outlined by the 2020 Medicare Physician Fee Schedule Final Rule (MPFS). Among the most drastic of these changes is the newfound attention you will put on medical decision making (MDM) and time in your oncologist’s medical documentation. You’ll delete 99201 (Office or other outpatient visit for the evaluation and management of a new patient …) and choose from 99202-99215 instead.

Note: You’ll see a new symbol (a 5 point star) to denote you can bill these codes as a telehealth service (as in, all office E/M services except 99211), says Melanie Witt, RN, MA, an independent coding expert based in Guadalupita, New Mexico. Appendix P will also list all telehealth codes.

More info: Check out in-depth Oncology Coding Alert articles “Part 1: Nix 99201 From Your New Patient Office E/M Codes in 2021” (volume 22, number 3), “Part 2: Here’s How Established Office E/M Codes Will Shift in 2021” (volume 22, number 6), and “Part 3: Manage Your MDM Component Expectations When 2021 Hits” (volume 22, number 10) for more information.

2. Prepare to Use New Prolonged Services

You will also need to learn about new prolonged services codes.

Note that +99354 (Prolonged service(s) in the outpatient setting requiring direct patient contact beyond the time of the usual service; first hour (List separately in addition to code for outpatient Evaluation and Management or psychotherapy service, except with office or other outpatient services [99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215])) and +99355 (… each additional 30 minutes (List separately in addition to code for prolonged service)) are add-on codes that you cannot report with 99202-99205 or 99212-99215.

However, you can use +99415 (Prolonged clinical staff service (the service beyond the highest time in the range of total time of the service) during an evaluation and management service in the office or outpatient setting, direct patient contact with physician supervision; first hour (List separately in addition to code for outpatient Evaluation and Management service)) and +99416 (… each additional 30 minutes (List separately in addition to code for prolonged service) with 99202-99205 and 99212-99215.

You also have new code +99417 (Prolonged office or other outpatient evaluation and management service(s) beyond the minimum required time of the primary procedure which has been selected using total time, requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service, each 15 minutes of total time (List separately in addition to codes 99205, 99215 for office or other outpatient Evaluation and Management services)).

Important: These prolonged services codes to be used with the new E/M guidelines for time-based coding.

Is your oncologist doing rounds? You could also report +99356 (Prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service; first hour (List separately in addition to code for inpatient or observation Evaluation and Management service).

Heads up: You will see other revised codes for chronic and complex care management, but you can breathe a sigh of relief. Your oncologist probably won’t need these codes. Primary care practices typically manage the patient’s care of multiple chronic diseases and therefore will be the provider most impacted by these revised codes.

3. Update to These Breast Codes

Revised breast codes 11970-11971 and 19328 include just more medically appropriate language, but the substance of the codes has not changed, Witt says. For instance, code 19328 will change from “Removal of intact mammary implant” to “Removal of intact breast implant.” So, if your surgical oncologist performs these procedures, you’ll continue reporting them.

For a simple implant removal, you’ll use revised code 19330 which will change to say, “Removal of ruptured breast implant, including implant contents (eg, saline, silicone gel).” The new descriptor indicates the implant is “ruptured,” which will differentiate this code from the verbiage change in 19328. You’ll also see in the CPT^® code book, “implant material” was removed.

Another revision is 19340, which will change to say, “Insertion of breast implant on same day of mastectomy (ie, immediate).” The old description for this code specifically included immediate prosthesis insertion after not just a mastectomy but also after mastopexy and/or reconstruction, Pickering says. The new description is only for post mastectomy. They also replaced the word “prosthesis” with “implant.”

You should note the revision to 19342, which will change to say, “Insertion or replacement of breast implant on separate day from mastectomy.” The old description for this code specifically included delayed prosthesis insertion after not just a mastectomy but also after mastopexy and/or reconstruction. The new description is only for post mastectomy. They also replaced the word “prosthesis” with “implant,” Pickering says.

Additionally, you’ll revise 19357, which will soon say, “Tissue expander placement in breast reconstruction, including subsequent expansion(s).” The old description for this code was confusing, stating “breast reconstruction, immediate or delayed, with tissue expander.” You’ll use this code with breast reconstruction codes as an add on when the oncologist inserts a tissue expander. Previously, the way the description read, it seemed as if the breast reconstruction was included, Pickering says.

Finally, you have the following breast procedure codes to both revise and delete:

4. Shift Your Lung Biopsy Codes

As of January 1, you’ve got a lung or mediastinum biopsy change to note.

You have new code 32408 (Core needle biopsy, lung or mediastinum, percutaneous, including imaging guidance, when performed), and you will delete code 32405 (Biopsy, lung or mediastinum, percutaneous needle).

With this code removed, use 32408, which is a core biopsy of lung/mediastinum with guidance when performed. This new code includes radiological guidance, when performed. “Previously, the radiology guidance was separately coded,” Pickering said.

5. Don’t Overlook Other Interesting Changes

You will delete 49220 (Staging laparotomy for Hodgkins disease or lymphoma (includes splenectomy, needle or open biopsies of both liver lobes, possibly also removal of abdominal nodes, abdominal node and/or bone marrow biopsies, ovarian repositioning)). According to the AMA Advisory Board, this code was deleted due to low usage.

You also have a graduated temporary code. As of January 1, you will report regular CPT^® code 55880 (Ablation of malignant prostate tissue, transrectal, with high intensity-focused ultrasound (HIFU), including ultrasound guidance).

You will also find a new code for lung cancer screening, which is 71271 (Computed tomography, thorax, low dose for lung cancer screening, without contrast material(s)).

For those coding radiology oncology services, you have new code 76145 (Medical physics dose evaluation for radiation exposure that exceeds institutional review threshold, including report).

You’ll use these codes to “report the assessment and calculation of radiation dose and the potential adverse iatrogenic effects received by the patient that may require follow-up observation or treatment. This is a technical component only code, as this service is typically performed by a medical physicist,” according to The American College of Radiology (https://www.acr.org/Advocacy-and-Economics/Coding-Source/March-April-2020/2021-Anticipated-Code-Changes).