AMA Releases 2019 Coding Changes

The American Medical Association (AMA) has released the 2019 Current Procedural Terminology (CPT^®) code set. The code set for the coming year includes 335 code updates as well as significant changes to certain descriptors.

According to the announcement from the AMA, the changes for 2019 reflect the “tremendous potential of using connected health tools to better support clinicians in patient population health and care coordination services, and other novel delivery systems that are vital for improving the overall quality of health care,” and are intended to “reflect how health care professionals can more effectively and efficiently use technology to connect with their patients at home and gather data for care management and coordination.”

The following are key changes included in the 2019 code set which is currently scheduled to go into effect January 1.

·         Six new Evaluation and Management (E&M) codes.

·         Guidelines revised for Interprofessional Telephone/Internet/Electronic Health Record Consultations.

·         New codes 99451 and 99152 added to report assessment and management services, based on medical consultative time.

·         New CPT codes 99453 and 99454 added to report remote physiologic monitoring services during a 30-day period.

·         Other codes in this section (99446-99449 and 99091) also revised.

·         New CPT code 99457 requires live, interactive communication with the patient/caregiver and 20 minutes or more of clinical staff/physician or other qualified health care professional time in a calendar month.

·         Fine needle aspiration (FNA) codes received new instructional notes including the definition of a fine needle aspiration and a core needle biopsy.

·         Imaging guidance added to nine new codes and reporting imaging guidance separately is no longer reportable.

·         Guidelines direct that the codes are selected based in guidance (included) and add on-codes for each additional lesion, same imaging modality.

o    When using different imaging modalities when more than one lesion is involved, Modifier 59 is appended.

o    CPT code 10021 (FNA) without imaging guidance is reported.

·         CPT code 10022 was deleted and replaced with CPT 10004 for each additional lesion.

·         CPT codes 10005-10012 were added to report the specific imaging guidance (ultrasound, fluoroscopic guidance, CT and MRI).

·         CPT codes 11100 and 11101 for skin biopsies were deleted.

·         New guidelines for coding biopsies.

·         Six new codes (11102-11107) for skin biopsies based on method of removal including tangential (shave, scoop, saucerize, curette), punch and incisional.

·         CPT codes 20932-20934 added for allografts.

o    CPT 20932 includes templating, cutting, placement and internal fixation; osteoarticular.

o    CPT 20933 is hemicortical, intercalary, partial.

o    CPT 20934 is hemicortical, complete.

·         CPT 27369 added to report an injection procedure for contrast knee arthrography or contrast enhanced CT/MRI knee arthrography.

·         CPT code 27370 was deleted likely due to being reported incorrectly as arthrocentesis or aspiration.

·         New CPT codes 33274 and 33274 are used for reporting a transcatheter insertion or replacement and removal of a permanent leadless pacemaker, right ventricle.

·         Codes 33285 and 33286 have been created for the insertion and removal of a subcutaneous cardiac rhythm monitor.

·         CPT 33289 is for a transcatheter implantation of a wireless pulmonary artery pressure sensor.

·         New CPT code 93264 is used to report remote monitoring of a wireless pulmonary artery pressure sensor for up to 30 days.

·         CPT 33440 was added for the replacement of the aortic valve by translocation.

·         CPT code 33866 created for an aortic hemiarch graft.

·         New CPT codes 36572 and 36573 are used for an insertion of a peripherally inserted central venous catheter (PICC) without a subcutaneous port or pump, based on age.

·         New CPT code 38531 is used to report a biopsy or excision of an open inguinofemoral lymph node.

·         Changes were made to the gastrostomy tube placement codes.

o    CPT code 43760 was deleted.

o    New CPT code 43762 is reported for the percutaneous gastrostomy tube placement including removal without imaging or endoscopic guidance not requiring revision of the gastrostomy tract.

o    CPT 43763 requires revision of gastrostomy tract.

·         CPT codes 50436 and 50437 are used to report dilation of existing tract, percutaneous for an endourologic procedure including imaging guidance with post procedural tube placement.

·         CPT 50437 is reported when new access into the renal collecting system is performed.

·         New CPT code 53854 was added to report a transurethral destruction of prostate tissue by radiofrequency generated water vapor thermotherapy.

·         New codes were established for ultrasound elastography, CPT 76981-76983 to distinguish reporting, per organ, first target lesion and each additional target lesion.

·         New CPT code 76391 is used to report Magnetic resonance (vibration) elastography.

·         Two new CPT codes 76978-76979 are used to report ultrasound procedures that use dynamic microbubble-sonographic contrast with targeted ultrasound to evaluation lesions.

·         Four new breast MRI procedures were added (77046-77049), based on laterality (unilateral vs. bilateral) and with or without contrast material.

·         CPT codes 77058 and 77059 were deleted.

·         CPT code 90689 was added to report an inactivated adjuvanted preservative free flu vaccination.

·         New CPT codes 92273 and 92274 were added in the Ophthalmology section to evaluate function of the retina and optic nerve of the eye.

o    CPT 92273 was added to report global response of photoreceptors of the retina.

o    CPT 92274 to report photoreceptors in multiple separate locations in the retina and macula.

•  CPT code 95836 (electrocorticogram) was added to report recording of EC_oG from electrodes chronically implanted on or in the brain to allow for intracranial recordings to continue after the patient has been discharged from the hospital.

·         New guidelines and new CPT codes were added to the Central Nervous System Assessments/Tests including 96112 and 91113 for developmental test administration based on time.

·         CPT add on code 96121 for a neuro behavioral status examination for ab additional hour was added.

·         Under Testing Evaluation Services CPT codes 96130-96133 were added for neuropsychological testing evaluation services based on time.

·         CPT codes 96136-96139 were added to report psychological or neuropsychological report testing and scoring, based on time and whether the service was performed by a technician or clinician.

o    CPT code 96146 is used to report psychological or neuropsychological automated testing using an electronic platform.

·         New codes for programming a neurostimulator were added with CPT odes 95976-95984. Codes, based on the nerve selected and simple versus complex.

·         Eight new CPT codes 97151-97158 and guidelines were added to Adaptive Behavioral services to address deficient adaptive behaviors.

·         Several pathology and laboratory codes and category III codes.

In the release, AMA President Barbara L. McAneny, MD, said the code set “is the foundation upon which every element of the medical community—doctors, hospitals, allied health professionals, laboratories and payers—can efficiently share accurate information about medical services”. McAneny added, “The latest annual changes to the CPT code set reflect new technological and scientific advancements available to mainstream clinical practice, and ensure the code set can fulfill its trusted role as the health system’s common language for reporting contemporary medical procedures. That’s why we believe CPT serves both as the language of medicine today and the code to its future.”

Some ICD-10-CM Codes Expanded for 2019

If you are a particularly observant medical coder, you’ve probably noticed that many codes identified as deleted were actually promoted to new roles. Nearly 50 codes were revamped to become parent codes of more specific codes,and it’s causing some confusion because some electronic coding systems mark them as deleted AND new.

Same Codes Marked as Deleted/New

Take C43.11  Malignant melanoma of right upper eyelid, including canthus, for example. Marked “no change” in the 2019 ICD-10-CM Addendum by CMS, the code received two new codes indented underneath for added specificity.

C43.111 Malignant melanoma of right upper eyelid, including canthus

C43.112 Malignant melanoma of right lower eyelid, including canthus

The next code, C43.12 Malignant melanoma of left upper eyelid, including canthus also received new codes. However, depending on the your encoder, it will show the code as both deleted and new.

Other codes are receiving this treatment, and it’s a good idea to keep your wits about you as you identify them in reports. Be sure to report the inconsistency to your coworkers and supervisors, along with your look-up program, encoder, and EMR provider.

C43.11 Malignant melanoma of right eyelid, including canthus

43.12 Malignant melanoma of left eyelid, including canthus

C4A.11 Merkel cell carcinoma of right eyelid, including canthus

C4A.12 Merkel cell carcinoma of left eyelid, including canthus

C44.102 Unspecified malignant neoplasm of skin of right eyelid, including canthus

C44.109 Unspecified malignant neoplasm of skin of left eyelid, including canthus

C44.112 Basal cell carcinoma of skin of right eyelid, including canthus

C44.119 Basal cell carcinoma of skin of left eyelid, including canthus

C44.122 Squamous cell carcinoma of skin of right eyelid, including canthus

C44.129 Squamous cell carcinoma of skin of left eyelid, including canthus

C44.192 Other specified malignant neoplasm of skin of right eyelid, including canthus

C44.199 Other specified malignant neoplasm of skin of left eyelid, including canthus

D03.11 Melanoma in situ of right eyelid, including canthus

D03.12 Melanoma in situ of left eyelid, including canthus

D04.11 Carcinoma in situ of skin of right eyelid, including canthus

D04.12 Carcinoma in situ of skin of left eyelid, including canthus

D22.11 Melanocytic nevi of right eyelid, including canthus

D22.12 Melanocytic nevi of left eyelid, including canthus

D23.11 Other benign neoplasm of skin of right eyelid, including canthus

D23.12 Other benign neoplasm of skin of left eyelid, including canthus

E72.8 Other specified disorders of amino-acid metabolism

E78.4 Other hyperlipidemia

F53 Mental and behavioral disorders associated with the puerperium, not elsewhere classified

G51.3 Clonic hemifacial spasm

G71.0 Muscular dystrophy

H57.8 Other specified disorders of eye and adnexa

I63.8 Other cerebral infarction

K35.2 Acute appendicitis with generalized peritonitis

K35.3 Acute appendicitis with localized peritonitis

K35.89 Other acute appendicitis

K61.3 Cholangitis

M79.1 Myalgia

N35.8 Other urethral stricture

N35.9 Urethral stricture, unspecified

O86.0 Infection of obstetric surgical wound

P02.7 Newborn affected by chorioamnionitis

P04.1 Newborn affected by other maternal medication

P04.8 Newborn affected by other maternal noxious substances

P74.2 Disturbances of sodium balance of newborn

P74.3 Disturbances of potassium balance of newborn

P74.4 Other transitory electrolyte disturbances of newborn

Q51.2 Other doubling of uterus

Q93.5 Other deletions of part of a chromosome

R82.99 Other abnormal findings in urine

R93.8 Abnormal findings on diagnostic imaging of other specified body structures

Z04.8 Encounter for examination and observation for other specified reasons

Z13.4 Encounter for screening for certain developmental disorders in childhood

2019 OFFICIAL GUIDELINES ICD-10-CM

Changes coming with 2019 Official Guidelines for Coding and Reporting of ICD-10-CM

The 2019 Official Guidelines for Coding and Reporting of ICD-10-CM have been released, and they certainly encompass some notable changes, as always.

Changes occur in the “Conventions,” the “General Guidelines,” and several chapter-specific guidelines as well. Narrative changes appear in bold text below; items underlined have been moved within the guidelines since the FY-2018 version; and italics are used to indicate revisions to heading changes. The effective date for these changes is Oct. 1, 2018.

Within the coding “Conventions,” convention No. 15, “with,” there is added wording in bold: The word “with” or “in” should be interpreted to mean “associated with” or “due to” when it appears in a code title, the Alphabetic Index (either under a main term or subterm), or an instructional note in the Tabular List. 

For General Guideline No. 14, the title is revised and has new instructions, plus the addition of guidance regarding “social determinates.” Health information management (HIM) coding professionals should read over this guideline change carefully.

For General Guideline No. 14, Documentation by Clinicians Other than the Patient's Provider, code assignment is based on the documentation by the patient's provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing the patient's diagnosis). There are a few exceptions, such as codes for the body mass index (BMI), depth of non-pressure chronic ulcers, pressure ulcer stage, coma scale, and National Institutes of Health NIH stroke scale (NIHSS). Code assignment may be based on medical record documentation from clinicians who are not the patient’s provider (i.e., the physician or other qualified healthcare practitioner legally accountable for establishing the patient’s diagnosis), since this information is typically documented by other clinicians involved in the care of the patient (e.g., a dietitian often documents the BMI, a nurse often documents the pressure ulcer stages, and an emergency medical technician often documents the coma scale).

For social determinants of health (SDoH), such as information found in categories Z55-Z65, Persons with potential health hazards related to socioeconomic and psychosocial circumstances, code assignment may be based on medical record documentation from clinicians involved in the care of the patient who are not the patient’s provider, since this information represents social information, rather than medical diagnoses.

The BMI, coma scale, NIHSS codes and categories Z55-Z65 should only be reported as secondary diagnoses.

In the “General Guidelines” section, there is a new General Guideline, No. 19: Coding for Healthcare Encounters in Hurricane Aftermath. To wit: 

1.    a. Use of External Cause of Morbidity Codes: An external cause of morbidity code should be assigned to identify the cause of the injury (or injuries) incurred as a result of the hurricane. The use of external cause-of-morbidity codes is supplemental to the application of ICD-10-CM codes. External cause-of-morbidity codes are never to be recorded as a principal diagnosis (first-listed in non-inpatient settings). The appropriate injury code should be sequenced before any external cause codes. The external cause-of-morbidity codes capture how the injury or health condition happened (cause), the intent (unintentional or accidental; or intentional, such as suicide or assault), the place where the event occurred, the activity of the patient at the time of the event, and the person’s status (e.g., civilian, military). They should not be assigned for encounters to treat hurricane victims’ medical conditions when no injury, adverse effect, or poisoning is involved. External cause-of-morbidity codes should be assigned for each encounter for care and treatment of injury. External cause-of-morbidity codes may be assigned in all healthcare settings. For the purpose of capturing complete and accurate ICD-10-CM data in the aftermath of a hurricane, a healthcare setting should be considered as any location where medical care is provided by licensed healthcare professionals.

37. b. Sequencing of External Causes of Morbidity Codes: Codes for cataclysmic events, such as a hurricane, take priority over all other external cause codes except child and adult abuse and terrorism, and should be sequenced before other external cause-of-injury codes. Assign as many external cause-of-morbidity codes as necessary to fully explain each cause. For example, if an injury occurs as a result of a building collapse during a hurricane, external cause codes for both the hurricane and the building collapse should be assigned, with the external causes code for hurricane being sequenced as the first external cause code. For injuries incurred as a direct result of the hurricane, assign the appropriate code(s) for the injuries, followed by the code X37.0-, Hurricane (with the appropriate seventh character), and any other applicable external cause-of-injury codes. Code X37.0- also should be assigned when an injury is incurred as a result of flooding caused by a levee breaking related to the hurricane. Code X38.-, Flood (with the appropriate seventh character), should be assigned when an injury is from flooding resulting directly from the storm. Code X36.0.-, Collapse of dam or manmade structure, should not be assigned when the cause of the collapse is due to the hurricane. Use of code X36.0- is limited to collapses of manmade structures due to earth surface movements, not due to storm surges directly from a hurricane.

37. c. Other External Causes of Morbidity Code Issues: For injuries that are not a direct result of the hurricane, such as an evacuee who has incurred an injury as a result of a motor vehicle accident, assign the appropriate external cause-of-morbidity code(s) to describe the cause of the injury, but do not assign code X37.0-, Hurricane. If it is not clear whether the injury was a direct result of the hurricane, assume this is the case and assign code X37.0-, Hurricane, as well as any other applicable external cause-of-morbidity codes. In addition to code X37.0-, Hurricane, other possible applicable external cause of morbidity codes include: W54.0-, Bitten by dog; X30-, Exposure to excessive natural heat; X31-, Exposure to excessive natural cold; or X38-, Flood.

59. d. Use of Z Codes: Z codes (other reasons for healthcare encounters) may be assigned as appropriate to further explain the reasons for presenting for healthcare services, including transfers between healthcare facilities. The ICD-10-CM Official Guidelines for Coding and Reporting identify which codes may be assigned as principal or first-listed diagnosis only, secondary diagnosis only, or principal/first-listed or secondary (depending on the circumstances). Possible applicable Z codes include: Z59.0, Homelessness; Z59.1, Inadequate housing; Z59.5, Extreme poverty; Z75.1, Person awaiting admission to adequate facility elsewhere; Z75.3, Unavailability and inaccessibility of healthcare facilities; Z75.4, Unavailability and inaccessibility of other helping agencies; Z76.2, Encounter for health supervision and care of other healthy infant and child; or Z99.12, Encounter for respirator (ventilator) dependence during power failure.

The external cause-of-morbidity codes and the Z codes listed above are not an all-inclusive list. Other codes may be applicable to the encounter based upon the documentation. Assign as many codes as necessary to fully explain each healthcare encounter. Since patient history information may be very limited, use any available documentation to assign the appropriate external cause-of-morbidity and Z codes. 

 Within the “Chapter-Specific Guidelines,” the first change we see is in Chapter 1, Certain Infectious and Parasitic Diseases, for sepsis, under the heading of Sepsis due to a post-procedural infection.

For infections following a procedure, a code from T81.40 to T81.43, Infection following a procedure, or a code from O86.00 to O86.03, Infection of obstetric surgical wound, that identifies the site of the infection should be coded first, if known. Assign an additional code for sepsis following a procedure (T81.44) or sepsis following an obstetrical procedure (O86.04). Use an additional code to identify the infectious agent. If the patient has severe sepsis, the appropriate code from subcategory R65.2 should also be assigned with the additional code(s) for any acute organ dysfunction.

 For infections following infusion, transfusion, therapeutic injection, or immunization, a code from subcategory T80.2, Infections following infusion, transfusion, and therapeutic injection, or code T88.0-, Infection following immunization, should be coded first, followed by the code for the specific infection. If the patient has severe sepsis, the appropriate code from subcategory R65.2 should also be assigned, with the additional codes(s) for any acute organ dysfunction.

If a post-procedural infection has resulted in post-procedural septic shock, assign the codes indicated above for sepsis due to a post-procedural infection, followed by code T81.12-, Post-procedural septic shock. Do not assign code R65.21, Severe sepsis with septic shock. Additional code(s) should be assigned for any acute organ dysfunction. 

Within Chapter 1, there is also a small change/revision with “Zika virus infection.”

In Chapter 2, Neoplasms, the following small change was made under the sections Primary malignancy previously excised and Current malignancy versus personal history of malignancy:

When a primary malignancy has been previously excised or eradicated from its site, there is no further treatment (of the malignancy) directed to that site, and there is no evidence of any existing primary malignancy at that site, a code from category Z85, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy.

 When a primary malignancy has been excised but further treatment, such as an additional surgery for the malignancy, radiation therapy, or chemotherapy is directed to that site, the primary malignancy code should be used until treatment is completed.

Subcategories Z85.0-Z85.7 should only be assigned for the former site of a primary malignancy, not the site of a secondary malignancy. Codes from subcategory Z85.8- may be assigned for the former site(s) of either a primary or secondary malignancy included in this subcategory.

 For Chapter 5, Mental, Behavioral, and Neurodevelopmental Disorders, the following notable changes and the addition of “Factitious Disorder” guideline have been made:

3) Psychoactive Substance Use, Unspecified: As with all other unspecified diagnoses, the codes forunspecified psychoactive substance use (F10.9-, F11.9-, F12.9-, F13.9-, F14.9-, F15.9-, F16.9-, F18.9-, F19.9-) should only be assigned based on provider documentation and when they meet the definition of a reportable diagnosis (see Section III, Reporting Additional Diagnoses).

1.    c. Factitious Disorder

Factitious disorder imposed on self, or Munchausen’s syndrome, is a disorder in which a person falsely reports or causes his or her own physical or psychological signs or symptoms. For patients with documented factitious disorder on self or Munchausen’s syndrome, assign the appropriate code from subcategory F68.1-, Factitious disorder imposed on self.  

Munchausen’s syndrome by proxy (MSBP) is a disorder in which a caregiver (perpetrator) falsely reports or causes an illness or injury in another person (victim) under his or her care, such as a child, an elderly adult, or a person who has a disability. The condition is also referred to as “factitious disorder imposed on another” or “factitious disorder by proxy.” The perpetrator, not the victim, receives this diagnosis. Assign code F68.A, Factitious disorder imposed on another, to the perpetrator’s record. For the victim of a patient suffering from MSBP, assign the appropriate code from categories T74, Adult and child abuse, neglect and other maltreatment, confirmed, or T76, Adult and child abuse, neglect and other maltreatment, suspected. 

See Section I.C.19.f. Adult and child abuse, neglect and other maltreatment

 There are other changes/revisions in the following chapters, and these should be read through thoroughly:

• Chapter 9, Diseases of the Circulatory System (Hypertension with Heart Disease; Hypertensive Chronic Kidney Disease; and Subsequent Acute Myocardial Infarction)
• Chapter 15, Pregnancy, Childbirth and the Puerperium (Drug use during pregnancy, childbirth and the puerperium)
• Chapter 18, Symptoms, Signs and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (Glasgow coma scale)
• Chapter 19, Injury, Poisoning, and Certain Other Consequences of External Causes (burns of the same anatomic site; underdosing; adult and child abuse, neglect and other maltreatment)
• Chapter 21, Factors Influencing Health Status and Contact with Health Service (Body Mass Index; Prophylactic Organ Removal)
• Be sure to learn more about these and other changes, and be ready for Oct. 1. All hospital inpatient and outpatient (including physician office) coding professionals are to apply the new guidelines for discharges occurring from Oct. 1, 2018 through Sept. 30, 2019. It’s also important for clinical documentation improvement (CDI) professionals to review the changes.