2017 charge master update - hfma nj...2017 outlier payment -apc • outlier payments: –cy 2017...

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2017 CHARGE MASTER UPDATE

presented by Yvette M. DeVay, MHA, CPC, CIC, CPC-I

Craneware, Inc.

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Coding Changes

CPT (792)Updates to CPT codes effective on January 1, 2017.

• 111 added codes. • 81 deleted or replaced codes.• 78 modified codes.

Updates to HCPCS codes effective on January 1, 2017.• 243 added codes. • 146 deleted or replaced codes.• 127 modified codes.

Updates to Modifier codes effective on January 1, 2017.• 6 added codes.

C-APC 25 new C-APCs

ICD-10 (6,758)ICD-10-CM

• 1,956 new codes.• 313 deletions.• 351 revised codes proposed for the 2017 release

of ICD-10-CM.ICD-10-PCS

• 3,651 are new codes.• 487 code revisions.

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Coding Changes

2014: 550 Year End Changes




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Your Chargemaster The Cornerstone of the Revenue Cycle

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REGULATORY CHANGES: 2017 OPPS

FINAL RULE

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CY 2017 OPPS FINAL RULE

AGENDA

• OPPS Payment and Ratesetting

• APCs/Packaging

• OPPS Payment for Devices/Drugs

• Non-Recurring Policies

• Hospital Outpatient Quality Reporting Program & Other Incentive-based Programs

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Learning Objectives

In our session, we will cover the following:

• 2017 Outpatient Prospective Payment System and Medicare Physician Fee Schedule Final Rule Regulatory Changes and their respecitve impact on the charge master and charge capture process

• CPT code additions, revisions, and deletions for 2017

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Code Disclaimer

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All CPT codes are copyrighted by the American Medical Association

All revenue codes (UB-04) are copyrighted by the American Hospital Association / National Uniform Billing Committee

Reproduction of either the CPT code, Revenue Code or this presentation without the consent of the appropriate parties may constitute a copyright violation.

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Statutory and Regulatory Guiduance

• Where to find them

• OPPS Proposed Rule– https://www.gpo.gov/fdsys/pkg/FR-2016-07-14/pdf/2016-16098.pdf

• OPPS Final Rule– https://www.gpo.gov/fdsys/pkg/FR-2016-11-14/pdf/2016-26515.pdf

https://www.gpo.gov/fdsys/pkg/FR-2016-07-14/pdf/2016-16098.pdf


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2017 OPPS Data and Tables

• Found on the CMS Website

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices-Items/CMS-1656-FC.html?DLPage=1&DLEntries=10&DLSort=2&DLSortDir=descending

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CY 2017 OPPS Payment and Ratesetting

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CY 2017 OPPS Payments/Ratesetting

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Component Value

Hospital Market Basket 2.7%

MFP -0.3%

ACA Adjustment -0.75%

Final: 1.65%

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• OPD Hospitals that fail to meet the Hospital Outpatient Quality Reporting (OQR) Program reporting requirements are subject to additional reduction of 2.0 percentage points from the OPD fee schedule increase factor that would be used to calculate the calculate the $73.501

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Rural and Sole Community

• Rural Sole Community Hospitals (SCHs) and Essential Access Community Hospitals (EACHs):

– +7.1% payment adjustment to OPPS payments

– Excluding separately payable drugs, biologicals, and devices paid under pass-through, and items paid at charges reduced to costs

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• Cancer Hospitals:

– Continued Adjustments for cancer hospitals

– Continue payment adjustment to 11 cancer hospitals

– Proposed target payment-to-cost ratio (PCR) equal to 91% (equal to the weighted average PCR for other

OPPS hospitals)

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Cancer Hospital

• Payment Adjustments

– Cancer hospitals receive the full amount of diffence between payments for covered outpatient servcies under OPPS and a “pre-BBA amount”.

– Continued adjustments for 2017

– Based on Cost report data, the target payment-to-cost ratio (PCR) of .91 will be used for CY 2017 cancer hospital payment adjustment.

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Adjustments Made to 11 Cancer Hospitals

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Provider Number

Hospital NameEst. Percentage

Increase in OPPS Payments

050146 City of Hope 25.8%

050660 USC Norris Cancer Hospital 14.0%

100079 Sylvester Comprehensive Cancer Center 32.4%

100271 H. Lee Moffit Cancer Center 27.3%

220162 Dana-Farber Cancer Institute 49.8%

330154 Memorial Sloan-Kettering Cancer Center 50.4%

330354 Roswell Park Cancer Institute 30.0%

360242 James Cancer Hospital 37.9%

390196 Fox Chase Cancer Center 16.6%

450076 M.D. Anderson Cancer Center 52.3%

500138 Seattle Cancer Care Alliance 58.7%

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2017 Outlier Payment - APC

• Outlier Payments:

– CY 2017 Multiplier Threshold = 1.75 times the APC Rate

– CY 2017 Fixed Dollar Threshold = $3,825

– Outlier payments will continue to be made at 50 percent of the amount by which the cost of furnishing the service would exceed 1.75 X the APC payment amount

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Community Mental Health Center (CMHC)• CMHC Outlier Payment

– Will occur if the cost for partial hospitalization services, paid under APC 5853, exceeds 3.40 times the payment rate for for APC 5853 ($124.92)

– The payment will be 50 percent of the amount by which the cost exceeds 3.40 X APC 5853

• CMHC Outlier Cap

– Applied at the provider level

– 8 percent Limit

• Total outlier payments will be limited to no more that 8 percent of the total per diem payments.

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APC UPDATE

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Packaging

• Apply at the claim level versus date of service level.

–Moving the edits from HCPCS level to claim level aligns with other packaging methodologies

• Packaging logic of the conditional packaging status indicators Q1 and Q2

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Packaging

• Expansion of Molecular Pathology Laboratory Test Exception

– For CY 2017 CMS is finalizing its proposal to expand this laboratory packaging exclusion to ADLTs that meet the criteria of section 1834A(d)(5)(A) of the Act.

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Packaging

• Discontinued separate payment for “unrelated” laboratory tests

–Discontinue “L1” Modifier

• Background: The L1 modifier was implemented in CY 2014 to allow for separate payment of laboratory test when it met the following:

– The only service reported on the claim was a laboratory test

– Laboratory test(s) were unrelated to the claim’s other services

» Defined as services ordered by a different physician for a different diagnosis than the other services on the claim ( Q4 SI)

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Comprehensive APCs(C-APC) Update

• Expand C-APCs from 37 to 62 with the creation of 25 new C-APCs

• New C-APC specific to Hematopoietic Stem Cell Transplant

• Finalized the policy proposal to discontinue the requirement that a code combination (that qualifies for a complexity adjustment by satisfying the frequency and cost criteria thresholds) also not create a 2 times rule violation in the higher level or receiving APC as proposed. We are not otherwise changing the complexity adjustment

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Comprehensive APCs(C-APC) Update

• Complete list of C-APCs for 2017 can be found in Addendum J of the 2017 Final OPPS Rule

– https://www.cms.gov/apps/ama/license.asp?file=/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Downloads/CMS-1656-FC-2017-OPPS-FR-Addenda.zip

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https://www.cms.gov/apps/ama/license.asp?file=/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Downloads/CMS-1656-FC-2017-OPPS-FR-Addenda.zip

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C-APC Background

• C-APC Primary Service – J1

– Includes:

• All covered outpatient department services (OPD) on the outpatient claim reporting a primary service that has a status indicator of J1

– Excludes non-covered OPD services

• Therapy services rendered as part of the primary service

• All drugs, biologicals, and radiopharmaceuticals, regardless of cost

– Excludes pass-through payment status drugs and self-administered drugs

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C-APC Background

• Observation C-APC – J2

– Specific combinations of services that, when performed in combination with each other and reported on a hospital Medicare Part B outpatient claim, would allow for all other OPPS payable services and items reported on the claim

• Excluding all preventive services and certain Medicare Part B inpatient services) to be deemed adjunctive services representing components of a comprehensive service and resulting in a single prospective payment through C-APC 8011 for the comprehensive service based on the costs of all reported services on the claim

MLN Matters® Number: MM9486

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C-APC Background

• Complexity Adjustment Policy

– When multiple procedures are performed the procedure with the highest weight determines the “family”

– Uses the primary procedure and can adjust upward to a higher payment rate withiin the same family

– Utilize Addendum J to:

• Identify primary service and complexity adjustments

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C-APC Background

• Addendum J

–Contains three tabs –

• Rank for Primary Assignment

• Complexity Adjustment Evaluation

• Complexity Adjustments

–Utilize all three and work from left to right

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Appendix J Example: Percutaneous Lung Biopsy• Rank for Primary Assignment

• Complexity Adjustement Evaluation

• Complexity Adjustment

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CY 2017 OPPS: New C-APCs

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C-APC Updates

• Three new clinical families established to accommodate new C-APCs including

– Nerve procedures,

– Excision, biopsy,

– Incision and drainage procedures, and

– Airway endoscopy procedures.

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Allogeneic Hematopoietic Stem Cell

• New comprehensive C-APC – C-APC 5244 (Level 4 Blood Product Exchange and Related Services)– What is the actual service?

• The IV infusion of Hematopoietic stems cells from bone marrow, umbilical cord of peripheral blood from a donor to a recipeint

– Reported with CPT 38240• 38240 - Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor

– Status Indicator of J1– Issue?

• Donor collection procedures are not covered under OPPS, only the services of the recipient are covered

– The payment for donor services (acquistion) is packaged into the APC for the allogeneic HSCT when a transplant occurs in the outpatient setting.

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• C-APC 5244– Will allow for all service costs included on the claim to be packaged

into the C-APC payment rate

– CY 2017 payment rate - $27,752

– New UB-04 revenue code 0815 (Allogeneic Stem Cell Acquisition Services)

• CMS originally proposed 0819 – not finalized

– All services for stem cell acquistion from the donor should be billed under revenue code 0815; and

– Should be reported on the same date of service as the transplant procedure to ensure they are packaged for payment

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• Cost Center Discussion

– The Medicare cost report (Form CMS–2552–10) has been updated

– Cost Center 07700 will be added to Worksheet A, and all applicable worksheets

– New cost center, line, 77 will be used for all acquistion costs related to the allogeneic stem cell transplants.

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APC Update

• Single Procedure APC

– Blood and Blood Products: No Change!

• Exception: Revise P9072 to “Platelets, pheresis, pathogen reduced or rapid bacterial tested, each unit”

– Brachytherapy Sources: No Change!

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APC Update

• New Technology APCs

– CY 2016: 48 New Tech APCs

• Cost bands range from $0 to $100,000

– CY 2017: 51 New Tech APCs

• Cost bands range from $0 to $160,000

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New APC APC Group Title SI

1901 New Technology-Level 49 ($100,001-$120,000) S

1902 New Technology-Level 49 ($100,001-$120,000) T





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Consolidation of Imaging APCs

• Level 1 Strapping and Cast Application Procedures

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CY 2017 APC Group Title

5521 Level 1 Diagnostic Radiology without Contrast





5571 Level 1 Diagnostic Radiology with Contrast



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Payment Status Indicators

• Background

–Indicators assigned to CPT and HCPCS codes to describe payment

–Status Indicators for CY 2017 are found within Addendum D1

–Status Indicators paid under OPPS

–G, H, J1, J2, K, N, P, Q1, Q2, Q3, Q4, R, S, T, U and V

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Payment Status Indicators

• For CY 2017 the definition of status indicator “E” has been revised and essentially replaced with two status indators “E1” and “E2”

–E1: Items and Services: Not covered by any Medicare

–E2: Items and Services for which pricing information and claims data are not available

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Comment Indicators CY 2017

• Found in Addendum D2

– Four Comment Indicators for use in CY 2017 – three in effect for CY 2016

• New for CY 2017

– ‘‘NC’’—New code for the next calendar year or existing code with substantial revision to its code descriptor in the next calendar year as compared to current calendar year for which we requested comments in the proposed rule, final APC assignment; comments will not be accepted on the final APC assignment for the new code.

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Comment Indicators CY 2017

• “NI’’—New code for the next calendar year or existing code with substantial revision to its code descriptor in the next calendar year as compared to current calendar year, interim APC assignment; comments will be accepted on the interim APC assignment for the new code

• ‘‘NP’’—New code for the next calendar year or existing code with substantial revision to its code descriptor in the next calendar year as compared to current calendar year proposed APC assignment; comments will be accepted on the proposed APC assignment for the new code

• “CH”—Active HCPCS code in current and next calendar year, status indicator and/or APC assignment has changed; or active HCPCS code that will be discontinued at the end of the current calendar year

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Addendum B and “CH” Comment Indicator

• Utilize Addendum B to pinpoint services pertinent to your facility to determine areas of impact

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• Filter for services with the “CH” comment indicator

• Identify services within the scope of your organization

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• Example CPT code 19370 - Surgery of the Breast Capsule

• Information from CY 2017 Addendum B

• Information from CY 2016 Addendum B

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OPPS Payment for Devices

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Device Payment

• Device pass-through payment eligibility period

– 2 years, but no more than 3 (42 CFR 419.66(g)

• Expiration of 3 year period at end of calendar year

• Quarterly Expiration

– For devices newly approved in CY 2017

• Ineligible for pass-through payment CY 2017:

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Device-Intensive Procedures

• Found in Addendum P of the final rule (new CY 2017)

– CMS to assign device-intensive designation at HCPCS code level

• Previously at the APC level

– Device-intensive procedures are subject to all CY 2016 policies applicable to procedures assigned device-intensive status under the established methodology (including edits and credits)

–No Cost/Full or Partial Credit Devices: No Change!

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OPPS Payment: Drugs, Biologicals, and Radiopharmaceuticals

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Drugs, Biologicals, and Radiopharmaceuticals

• Separately Payable Drugs and Biologicals

– SI =K

• Packaged / Policy Packaged Drugs and Biologicals

– SI =N

• Pass Through Drugs and Biologicals

–SI =G

• Self Administered/Statutorily Excluded Drugs

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• A listing of Pass Through Drugs can be found in the OPPS Final Rule – Table 36

– Continued reimbursement at Average Sales Price (ASP)+6%

– Quarterly Expiration

• To allow for a pass-through period as close to three years as possible

– 15 drugs and biologicals will expire on December 31, 2016

– JW modifer – wastage regulations apply

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81 F.R. 79662

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• Separately Payable Drugs

– CY 2017 threshold for separately payable drugs (SI=K) has been set at $110.00

– Above $110 – separately payable

– Below $110 - drugs/biologicals will be packaged

– Reimbursed at ASP+6%

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Packaged Drugs and Biologicals

• Those that fall below the $110 threshold

• Always packaged independent of threshold

– Anesthesia, certain drugs, biologicals, and other pharmaceuticals; medical and surgical supplies and equipment; surgical dressings; and devices used for external reduction of fractures and Intraoperative items and services

– Drugs, biologicals, and radiopharmaceuticals that function as supplies when used in a diagnostic test or procedure (including but not limited to, diagnostic radiopharmaceuticals, contrast agents, and pharmacologic stress agents

– Drugs and biologicals that function as supplies when used in a surgical procedure (including, but not limited to, skin substitutes and similar products that aid wound healing and implantable biologicals)

– Status Indicator “N”12/9/2016 53

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• Diagnostic Radiopharmaceuticals– Policy packaged, those with pass - through status – continued for CY

2017

• Therapeutic Radiopharmaceuticals– Pass Through paid at ASP +6%– Separately payable therapeutic radiopharmaceuticals (per day cost of

> $110) - ASP +6%– Radiopharmaceuticals less than $110 will be packaged per the

packaging policies

• Continue the policy of providing an additional $10 payment for radioisotopes produced by non-HEU sources for CY 2017 - Q9969 HCPCS code

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• Continue to pay blood clotting factors at ASP+6%

• Biosimilar biological products:

– Proposing to continue the payment policy for biosimilar biological products as was implemented in CY 2016

– Payment methodology for separately payable drugs extended to biosimilars (ASP+6%)

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OPPS Payment for Hospital Outpatient Visits, Partial Hospitalization, and IP Only Procedures

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OPPS Payment for Hospital Outpatient Visits

• Clinic and ED Visits – No Change!

–CMS is not making changes to the current clinic, emergency department (ED) hospital outpatient visits and critical care services payment policies for CY 2017

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Partial Hospitalization

• Partial Hospitalization (PHP)

– Combine the existing two-tiered PHP APCs for Community Mental Health Centers (CMHCs) and hospital-based PHP APCs

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APC Description CY 2017 Rate

5853 CMHC Partial Hospitalization (3 or more Services Per Day) $135.30

5863Hospital-Based Partial Hospitalization (3 or more Services Per Day) $192.57

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Partial Hospitalization

Why the decreased number of levels?

– Avoidance of cost inversion due to the numbe rof providers in the PHP venue

– PHP Monitoring: CMS to monitor providers to assure that they meet the 20 hours/week of service requirement

– CMS to monitor the low frequency of individual therapy services – CMS expects to see an increase

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Inpatient Only List

• Inpatient Only Procedures – Addendum E

–Remove the following procedures:

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CPT Description

22840 Posterior non-segmental instrumentation

22842 Posterior segmental instrumentation; 3 to 6 vertebral segments

22845 Anterior instrumentation; 2 to 3 vertebral segments

22858 Total disc arthroplasty, anterior approach...; second level, cervical

31584 Laryngoplasty; with open reduction of fracture

31587 Laryngoplasty, cricoid split

22585 Arthrodesis, anterior interbody technique.; each add’l interspace


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Inpatient Only List

• The Challenge

–Status assignment

–Process/procedure prior to the surgical intervention for the identification of procedure conversion

–Post operative code review – Immediate?

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Non-Recurring Policy Changes

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Nonrecurring Policy Changes

• Payment Modifier for X-ray Films

– Effective 01-01-2017: Payment under the OPPS shall be reduced by 20 percent for X-rays taken using film

– New modifier applies to CPT codes for X-rays taken using film: FX

• Payments for X-rays taken using computed radiography

– Identical to the 2017 Medicare Physician Fee Schedule Final Rule – to be discussed later in the presentation

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Section 603 of the Bipartisan Budget Act 2015Off-Campus Departments

• As of January 1, 2017, applicable items and services furnished by certain off-campus outpatient departments of a provider will not be considered covered OPD services for purposes of payment under the OPPS (Section 1833(t)(1)(B)(v) and 1833(t)(21))

• Interim final rule for establishment of payment rates under the Medicare Physician Fee Schedule

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Off-Campus Provider-Based Department

• Designated, as such, in the Medicare system as of November 2, 2015

– Furnished services as of November 2, 2015 and billed for these services, under OPPS, in accordance with timely filing limits

• Will continue to be paid under OPPS

– Excepted off-campus PBDs would no longer be excepted if it relocates from the physical address that was listed on the enrollment form as of November 1, 2015, except if relocation is due to extraordinary circumstance

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• Off-Campus PBD before 11/2/15 cannot remain excepted and paid under OPPS if:– Change Locations

• Did not provide services at that location prior to 11/2/15

• Off-Campus PBD) before 11/2/15 can remain excepted and paid under OPPS if:– Change in ownership – must retain original provider

agreement– Temporary location – due to natural disaster

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• Location, Location, Location

• Paid Under OPPS– Dedicated Emergency Room (DED)– On Campus PBD – exempt – paid under OPPS– Off Campus PBD furnishing prior to 11/2/2015 – exempt

generally paid under OPPS

• Paid under applicable payment method– Off Campus PBD who began furnishing after 11/2/2015

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Off-Campus Provider-Based Departments

• Modifiers

– “PO” - "Services, procedures, and/or surgeries furnished at off-campus provider-based outpatient departments."

• Reported with every service (procedure code) for outpatient hospital items and services furnished in an off-campus provider-based department (PBD) of a hospital.

– “PN” – Indicates that the item or service is a nonexcepted item or service.

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Transplant Outcomes

• Transplant Program Acceptable Outcomes Standard:

– Ratio of observed patient deaths or graft failures divided by the risk-adjusted expected number

– Current expected ratio: Must remain below 1.5

– CMS is proposing to change the threshold from 1.5 to 1.85 (up to 9.7 graft losses out of 100 transplants (within 1 year of transplant))

– Use this threshold for all organ types and for both graft and patient survival

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Organ Procurement Organizations (OPOs)

• To receive payment from Medicare and Medicaid, the OPO must have an agreement with the Secretary and must meet performance standards as designated by the Secretary

• Donor/organ suitability (current)– The death of a patient who is 70 years old or younger– Legally declared brain dead according hospital policy– Does not exhibit active infections or other conditions,

including HIV

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Organ Procurement Organizations (OPOs)

• Donor/organ suitability (OPTN-effective1-1-2017)– The death of a patient 75 years old or younger– Replace the automatic exclusion of patients with Multi-

System Failure with clinical criteria for each organ type that specifies each type’s suitability for procurement

– Allow recovery and transplantation of organs from an HIV positive donor into an HIV positive recipient

• CMS will mirror OPTN Donor/organ suitability• CMS to no longer require paper documentation to be

sent with organ to receiving transplant center

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Hospital Outpatient Quality Reporting (OQR) Program

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Hospital Outpatient Quality Reporting Program

• CMS will update extraordinary circumstances exemption (ECE) policy to extend the ECE request deadline for both chart-abstracted and Web-based measures from 45 to 90 days following an event causing hardship

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Hospital Outpatient Quality Reporting Program

• CMS finalized seven new measures for the CY 2020 payment determination and subsequent years– OP-35: Admissions and Emergency Department Visits for Patient

Receiving Outpatient Chemotherapy

– OP-36: Hospital Visits after Hospital Outpatient Surgery

– OP-37a: OAS CAHPS – About Facilities and Staff

– OP-37b: OAS CAHPS – Communication About Procedure

– OP-37c: OAS CAHPS – Preparation for Discharge and Recovery

– OP-37d: OAS CAHPS – Overall Rating of Facility

– OP-37e: OAS CAHPS – Recommendation of Facility12/9/2016 74

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Hospital Value-Based Purchasing (VBP) Program

• Currently nine HCAHPS survey dimensions for FY 2018 in which discharged patients are asked 32 questions about their recent hospital stay

• CMS will remove the HCAHPS Pain Management dimension from the Hospital VBP beginning with the FY 2018 program year

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REGULATORY CHANGES:2017 MPFS FINAL RULE

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MedicareCY 2017

PFS Final RuleOverview

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What Will / Will Not We Cover ?

• We will be presenting regulatory changes of the MPFS Final Rule as it pertains to the physician environment

• We will not be covering:– Specific Changes in RVUs– MACRA/MIPs/APMs

• We will focus on:– Changes to Existing Methodologies under PFS– Regulatory Changes

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CY 2017 MPFS Final RuleAgenda

• 2017 Financial Impact• RVU Phase In Reduction• Procedures Subject to the

Multiple Procedure Payment Reduction

• Data Collection of Global Services

• Primary Care and Care Management

• Non-Face-to-Face Prolonged Services

• X-ray Transition Incentive• Telehealth Services• Physical Therapy Exception

Process• Medicare Advantage Enrollment• Off Campus-Departments• Quality Initiatives

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Background

• The Medicare Physician Fee Schedule Proposed and Final Rules historically address changes to the physician fee schedule and other Medicare Part B payment policies

• Updates are made to ensure that the payment system reflects changes in the medical practice, relative values of services, and statute

• Proposed Rule Publication Date – July 15, 2016

• Final Rule Display Date – November 2, 2016

• Final Rule Publication Date – November 15, 2016

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Statutory and Regulatory Guidance

• Where to find it?

–PFS Final Rule •https://s3.amazonaws.com/public-inspection.federalregister.gov/2016-26668.pdf

–PFS Proposed Rule•https://www.gpo.gov/fdsys/pkg/FR-2016-07-15/pdf/2016-16097.pdf

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https://s3.amazonaws.com/public-inspection.federalregister.gov/2016-26668.pdf


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2017 Final Rule

• Beginning with the 2017 MPFS Final rule, Finalized without comments

• Second year of rule-making without SGR

• All comments are reviewed and finalized prior to the Final Rule– Aids in the transparency in rate setting

• Effective date is January 1, 2017– Exception:

• The claims-based data collection mandatory reporting of post-operative 10 and 90 day global services is July 1, 2017

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2017 PFSFINANCIAL IMPACT

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Summary of Major Changes 2017

• CY 2017 Financial Impact– Conversion Factor is $35.8887

• Reflects:

–The budget neutrality adjustment;

– .5 percent update adjustment factor specified under §1848(d) of the Act;

–Adjustment due to the non-budget neutral 5 percent MPPR for the professional component of imaging services, and

–-0.18 percent target recapture rate required under §1848(c)(2)(O)(iv) of the Consolidated Appropriations Act of 2016

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Summary of Major Changes 2017

• Geographical Price Cost Indices (GPCIs)– Update

• Routine, with no significant change to most localities

– Exception: • New California locality structure

– Consistency between the territories of Puerto Rico and the Virgin Islands

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Statutory Phase-In of Significant RVU Reductions

• RVU Reductions for Services–The phase-in reduction of RVUs was introduced

in the 2016 MPFS Final Rule–For revaluated services, in which the decrease

amounted to more than 20 percent of the total RVUs – the reduction was to take place over a 2 year period

–Only applies to existing codes

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Statutory Phase-In of Significant RVU Reductions

• RVU Reductions for Services

– CMS failed to address scenarios where the remaining reduction in the consecutive year was greater than 20 percent.

– The Final Rule, indicates that the 19 percent reduction in total RUVs will continue to maximum reduction for all codes, including codes with a phase-in value from the previous year.

– Every code, is evaluated each year and the phase-in is limited to a 19 percent decrease.

– Phase-in transition will apply until the year-to-year reduction for a code does not meet the 20 percent threshold.

12/9/2016 87

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Statutory Phase-In of Significant RVU Reductions• RVU Reductions for Services

– A total of 82 procedure code subject to the phase-in reduction are named in the Final Rule and effect multiple specialties

– A list of codes subject to the phase in reduction is available on the CMS website

• https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1654-f.html

12/9/2016 88

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1654-f.html

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Procedures Subject to the Multiple Procedure Payment Reduction (MPPR) and the OPPS Cap• Payment reduction of the professional component of

procedures has been revised under §1848(b)(10) of the Consolidated Appropriations Act

• Payment reduction revised from 25 percent to 5 percent beginning January 1, 2017

• The public use files for CY 2017 are available on the CMS website under downloads for the CY 2017 PFS final rule at:– https://www.cms.gov/Medicare/Medicare-Fee-for-Service-

Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1654-f.html.

http://www.cms.gov/Medicare-Fee-for-ServicePayment/PhysicianFeeSched/PFSFederal-Regulation-Notices.html.

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Physical Therapy Cap Exception Process

• MACRA and Exception Process– Extended through December 31, 2017

– Now includes outpatient therapy services furnished by hospitals

• CY 2017 Therapy Cap– $1,980

12/9/2016 90

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12/9/2016 91

GLOBAL SERVICESDATA COLLECTION

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Claims-based Data Collection of 10 and 90 Day Global Services

• Global Surgery Reporting Background– In CY 2015 the policy to transform all procedures with 10 and 90 day

global periods into 0 day global periods was finalized

• Conversion

–CY 2017 – 10 day

–CY 2018 – 90 day– MACRA prohibited the implementation of the 2015 finalized policy

• Required CMS to develop and implement a process to collect data from a representative sample of physicians.

• The collected data must be utilized in the valuation of E/M services beginning in CY 2019

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• The Finalized Data Collection Process– Differs from the process in the CY 2017 Proposed Rule

• Mandatory Reporting will begin on July 1, 2017 and not January 1st, as proposed.

• Not all practitioners are required to report

• Data Collection is only mandatory for physicians who meet the following:

– Group practices (10 or more) physicians in the following states:

» Florida, Kentucky, Louisiana, Nevada, New Jersey, North Dakota, Ohio, Oregon, and Rhode Island

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• Finalized Claims-based Data Collection

– Practitioners will only report on 10 and 90 global surgery codes that meet the following conditions:• Reported annually by more than 100 practitioners; • Reported more than 10,000 times; or • Allowed charges in excess of $10 million annually

– CPT code 99024 will be used for reporting post-operative services rather than the proposed set of G-codes• No reporting of pre-operatives visits included in the global

package or services which are unrelated to patient visit

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• Finalized Claims-based Data Collection– Voluntary Reporting

•Practitioners outside of listed states are welcome to report on a voluntary basis

• If participating on a voluntary basis report all visits for all required codes.

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Payment Incentive for Transition from Traditional X-Ray to Digital Radiography

• Reimbursement for the technical component of X-rays taken with plain film will be reduced by 20 percent in 2017 and all subsequent years.

• FX modifier– Established to be reported on claims that include X-ray

imaging services that are taken using film.

• Appending the modifier will result in the 20 percent reduction in PFS payment amount for the technical component or the technical component of a global service.

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Payment Incentive for Transition from Traditional X-Ray to Digital Radiography

• Computed Radiography–Reimbursement for computed radiography

technical component will be reduced by 7 percent between 2018 and 2022

–Ten percent reduction for 2023 and subsequent years

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MODERATE SEDATION

12/9/2016 98

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Revaluation of Moderate Sedation Service

• Background– For 2017 Appendix G has been removed and the CPT Manual – The CPT Editorial Panel deleted the existing moderate sedation

services– Six new codes have been created for moderate sedation

• In Response– CMS finalized the values for the new CPT codes and adopted a uniform

methodology for valuation of the procedure codes in which moderate sedation is inherent to the procedure

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2017 Moderate Sedation Service Codes

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Revaluation of Appendix G Services

• CMS believes that RVUs assigned under the PFS should reflect the overall relative resources of the service independent of the number of codes used to report the services

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• Based on data available, it was determined that gastroenterologists furnish the highest volume of services in Appendix G– Led to the belief that duplicative payment was made for such codes

• Creation of the endoscopy-specific moderate sedation G-code– G0500: Moderate sedation services provided by the same physician or other

qualified health care professional performing a gastrointestinal endoscopic service that sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status; initial 15 minutes of intra-service time; patient age 5 years or older. (additional time may be reported with 99153, as appropriate).

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• Procedure codes will maintain their current RVU value less the work RVUs associated with the most frequently reported corresponding moderate conscious sedation code

• RVU of .10 was finalized for HCPCS code G0500 for the GI endoscopy procedures

• All other current Appendix G codes will see a .25 work RVU reduction

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• Table 26 of the 2017 MPFS Final Rule, lists the CY 2016 RVUs, the CY 2017 refined work RVUs and GI endoscopic services for which G0500 will be appended to report the moderate sedation services– The table is available for download

• https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1654-F.html?DLPage=1&DLEntries=10&DLSort=2&DLSortDir=descending

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1654-F.html?DLPage=1&DLEntries=10&DLSort=2&DLSortDir=descending

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TABLE 26: Valuations for Services Minus Moderate Sedation

Excerpt

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Mammography and Computer Aided Detection

• CMS finalized new coding based on the new CPT mammography codes for CY 2017

• The new codes 77065,77066, and 77067 • Bundle mammography with CAD when performed. • The structure of these codes is similar to the existing

mammography codes– unilateral diagnostic mammography, – bilateral diagnostic mammography; and – screening mammography.

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• Three mammography codes were created by the CPT editorial panel– 77065 - Diagnostic mammography, including computer-

aided detection (CAD) when performed; unilateral

– 77066 - Diagnostic mammography, including computer-aided detection (CAD) when performed; bilateral

– 77067- Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed

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• Although, CMS has accepted the CPT coding, due to Medicare claims system processing issues the CPT codes are unable to be processed for CY 2017

• Given that the new codes are parallel in nature to the existing G-codes, G0202, G0204 and G0206, CMS will operationalize the new coding rules and the new code descriptors through the use of the existing G-codes

• For mammography services in CY 2017, the G codes are to be reported

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TELEHEALTH SERVICES

12/9/2016 109

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Expanded Coverage for Telehealth Services

• End-Stage Renal Disease (ESRD)

– CPT Codes 90967-90970• CPT 90967 End-stage renal disease (ESRD) related services for dialysis less than

a full month of service, per day; for patients younger than 2 years of age;

• CPT 90968 End-stage renal disease (ESRD) related services for dialysis less than a full month of service, per day; for patients 2-11 years of age;

• CPT 90969 End-stage renal disease (ESRD) related services for dialysis less than a full month of service, per day; for patients 12-19 years of age; and

• CPT 90970 End-stage renal disease (ESRD) related services for dialysis less than a full month of service, per day; for patients 20 years of age and older.

12/9/2016 110

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• End-Stage Renal Disease (ESRD)

– Exception:

• Clinical examination of the catheter access site must be furnished face-to-face, “hands on” by a physician, CNS, NP or PA

12/9/2016 111

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• Advanced Care Planning

– CPT codes 99497 and 99498

• CPT 99497- Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), or surrogate); and

• CPT 99498 – Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; each additional 30 minutes (list separately in addition to code for primary procedure)

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• Telehealth Consultations for Patients Requiring Critical Care Services

–CPT codes G0508 and G0509• CPT G0508 - Telehealth consultation, critical care, initial , physicians

typically spend 60 minutes communicating with the patient and providers via telehealth

• CPT G0509 - Telehealth consultation, critical care, subsequent, physicians typically spend 50 minutes communicating with the patient and providers via telehealth

12/9/2016 113

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• Telehealth Consultations for Patients Requiring Critical Care Services–CPT codes G0508 and G0509

•Reported once per day per patient

•Valued related to existing E/M services

12/9/2016 114

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Telehealth Services Place of Service Code

• For services furnished for dates of service on or after January 1, 2017

• Place of service code 02 will be reported for telehealth services– 02 – Telehealth

• The location where health services and health related services are provided or received, through telecommunication technology

12/9/2016 115

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Telehealth Services

• Originating Site Facility Fee Payment

– HCPCS Code Q3014 - Telehealth originating site facility fee for CY 2017 will be the lesser of the following:

• $25.40; or

• 80 percent of actual charge

12/9/2016 116

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PRIMARY CARE AND

CARE MANAGEMENT

12/9/2016 117

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Non-Face-to-Face Prolonged E/M Services

• CMS has established separate payment for non-face-to-face services, CPT codes:

• 99358 – Prolonged evaluation and management service before and/or after direct patient care, first hour

• 99359 - Prolonged evaluation and management service before and/or after direct patient care, each additional 30 minutes (report in addition to code for prolonged service)

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Non-Face-to-Face Prolonged E/M Services

• CMS Intention– Billed and reported by billing physician or other

practitioner

• Not Clinical Staff

– Not to be reported with Chronic Care Management Services

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Chronic Care Management

• CMS will make separate payments for CPT codes 99487 and 99489

• Reduction of the administrative burden associated with chronic care management services through the modification of the scope of service chronic care elements:– Patient consent– Unified IT requirements – Continuity of Care– Patient seen within a year

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CCM Scope of Service Elements

• Initiating Chronic Care Management During a Visit

– CMS has revised the requirement that the CCM management be initiated during an AWV, IPPE or face-to-face EM visit

• Requirement has been lifted for the initiation during a visit if the patient has been seen in the last year.

• Previously the element indicated this applied to all patients, now only required if the patient is new or has not been seen in the last year

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• Continuity of Care

– CMS has removed the requirement of a designated practitioner with whom the beneficiary is able to get successive routine appointments from the continuity of care element

• The continuity of care requirement now states designated team member

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• Electronic Sharing of Care Plan– CMS has removed the restriction of communication of fax

only being used in extenuating situations• Fax transmission can now be used routinely

• Patient Consent– CMS has removed the requirement of the written

beneficiary consent• Practitioners are only required to inform the beneficiary of the

availability of Chronic Care Management services

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Psychiatric Collaborative Care Management and Behavioral Health Integration Services

• CMS has proposed payment for mental healthcare using the behavioral health Collaborative Care Model (CoCM) – Team-based approach

• Psychiatric consultant, • Behavioral health care manager, and • Primary care clinician.

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Psychiatric Collaborative Care Management and Behavioral Health Integration Services

• Psychiatric Collaborative Care Management– G0502, G0503,G0504

• Temporary to be used for one year and replaced with the CPT codes for 2018

• Capture the work of the primary care physician working with the specialist

• Behavioral Health Integration– G0507

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Psychiatric Collaborative Care Management

• The Psychiatric Collaborative Care Management is used to treat patients with common psychiatric conditions in the primary care setting through the provision of a defined set of services with one of the core concepts:– Patient centered team care/collaborative care– Population-based care– Measurement-based treatment to target; and– Evidenced based care

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• G0502: Initial psychiatric collaborative care management, first 70 minutes in the first calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional, with the following required elements:

– Outreach to and engagement in treatment of a patient directed by the treating physician or other qualified healthcare professional

– Initial assessment of the patient, including administration of validated rating scales, with the development of an individualized treatment plan;

– Review by the psychiatric consultant with modifications of the plan if recommended

– Entering patient in a registry and tracking patient follow-up and progress using the registry, with appropriate documentation, and participation in weekly caseload consultation with the psychiatric consultant; and

– Provision of brief interventions using evidence-based techniques such as behavioral activation, motivational interviewing, and other focused treatment strategies

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• G0503: Subsequent psychiatric collaborative care management, first 60 minutes in a subsequent month of care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional, with the following required elements:

– Tracking patient follow-up and progress using the registry, with appropriate documentation;

– Participation in weekly caseload consultation with the psychiatric consultant;

– Ongoing collaboration with and coordination of the patient's mental health care with the treating physician or other qualified health care professional and any other treating mental health providers;

– Additional review of progress and recommendations for changes in treatment, as indicated, including medications, based on recommendations provided by the psychiatric consultant;

– Provision of brief interventions using evidence-based techniques such as behavioral activation, motivational interviewing, and other focused treatment strategies;

– Monitoring of patient outcomes using validated rating scales; and relapse prevention planning with patients as they achieve remission of symptoms and/or other treatment goals and are prepared for discharge from active treatment.

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• G0504: Initial or subsequent psychiatric collaborative care management, each additional 30 minutes in a calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional (List separately in addition to code for primary procedure) (Use G0504 in conjunction with G0502, G0503)

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Cognitive Impairment Assessment and Care Plan Services G0505

• CMS has finalized the provision of separate payment for cognitive impairment assessment care plan services

• Provided to patients when a comprehensive evaluation of a new or existing patient exhibiting signs of cognitive impairment is required to establish a diagnosis or the severity of the condition

• 10 Required Elements

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Cognitive Impairment Assessment and Care Plan Service

Required Elements

• Cognition – focused evaluation

• Medical decision making of moderate or high complexity

• Functional assessment

• Use of standardized instruments to stage dementia

• Medication reconciliation if applicable

• Evaluation for neuropsychiatric and behavioral symptoms

• Evaluation of safety (i.e. motor vehicle operation)

• Identification of caregivers, caregivers’ need, knowledge, social support

• Advanced care planning

• Creation of Care Plan

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Cognitive Impairment Assessment and Care Plan Services G0505

• All 10 elements must be met

• G0505 may be reported and billed with:– CCM services

• Provided to patients when a comprehensive evaluation of a new or existing patient exhibiting signs of cognitive impairment is required to establish a diagnosis or the severity of the condition

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MEDICARE ADVANTAGE PROVIDER ENROLLMENT

12/9/2016 133

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Medicare Advantage Provider Enrollment

• Need for regulatory action

– Providers or suppliers that furnish health care items or services to a beneficiaries receiving Medicare benefit through an MA organization will be required to be enrolled in Medicare and be in an approved status

– Applies to network providers and suppliers; first-tier, downstream, and related entities (FDR); suppliers in Cost HMOs or CMPs; providers and suppliers participating in demonstration programs; providers and suppliers in pilot programs; locum tenens suppliers; and incident-to suppliers.

– Finalized the prohibition on MA, PACE, the other designated programs and organizations from paying individuals or entities that are excluded by the OIG or revoked from the Medicare program

– Stakeholders will have 2 years to make necessary changes to meet requirements

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OFF-CAMPUS DEPARTMENTSSection 603 of the Bipartisan Budget Act of 2015

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Bipartisan Budget Act of 2015 – Section 603

• Beginning January 1, 2017 applicable items and services furnished by certain off-off campus departments of a provider will not be considered covered outpatient department services for the purposes of payment under the Outpatient Prospective Payment System

• Site Specific PFS rates

• Currently, Interim final rule for establishment of payment rates for the outpatient department under the Medicare Physician Fee Schedule with the comment period ending on 12/31/2016.

• Physicians will continued to be reimbursed at the non-facility rate

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QUALITY INITIATIVES

12/9/2016 137

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Medicare Diabetes Prevention Program (MDPP)

• Expansion of the duration and scope of the Diabetes Prevention Program (DPP) model test

• Goal – prevention of Type II diabetes among Medicare beneficiaries with pre-diabetes

• MDPP expanded model is a Center for Medicare and Medicaid Innovation (Innovation Center)

• Covered as an additional preventive service under Medicare

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• MDPP expanded model will become effective nationwide on January 1, 2018

• MDPP Core Benefit– 12 consecutive months and consists of at least 16 weekly core

sessions over months 1-6

– At least six monthly core maintenance sessions over months 6-12• The above services will be furnished regardless of weight loss

• MDPP expanded model will be implemented through at least two rounds of rulemaking

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• Supplier Requirements– High screening level

– Coaches must obtain National Provider Identifier (NPI)

– DPP organizations to enroll in Medicare as MDPP suppliers in order to furnish and bill for MDPP services

• Regardless of any existing enrollment in Medicare

– Must utilize CDC approved curriculum.• Preferred curriculum is available at:

– http://www.cdc.gov/diabetes/prevention/lifestyleprogram/curriculum.html

http://www.cdc.gov/diabetes/prevention/lifestyleprogram/curriculum.html

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Appropriate Use Criteriafor Advanced Diagnostic Imaging Services

• New program under the statute for fee for service Medicare to promote the use of appropriate use criteria (AUC) for advanced diagnostic imaging services.– Established under the Protecting Access to Medicare Act (PAMA)

2014, Section 218(b)

– The initial component mandated in the 2016 MPFS final rule• Specified appropriate use criteria

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• Proposed– Beginning January 1, 2017, the requirement for an

ordering professional to consult with a qualified CDSM when ordering an applicable imaging service that would be furnished in an applicable setting and paid for under an applicable payment system; and for the furnishing professional to include on the Medicare claim information about the ordering professional’s consultation with a qualified CDSM

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• The 2016 MPFS final rule– Evidenced based process and transparency requirements for the

development of AUC

– Defined provider-led entities (PLEs)

– Established process by which PLEs may become qualified to develop, modify or endorse AUC

– Qualified List of PLEs was posted to the CMS website in June of 2016 and can be found at:

• https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Appropriate-Use-Criteria-Program/PLE.html

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Appropriate-Use-Criteria-Program/PLE.html

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• 2017 MPFS Final Rule is focused on the next stage of the Medicare AUC program– Priority clinical areas,

– Clinical decision support mechanism (CDSM) requirements,

– CDSM application process, and

– Exceptions for ordering professionals for whom consultation with AUC would pose a significant hardship.

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• Finalized List of Priority Clinical Areas – Coronary artery disease (suspected or diagnosed)

– Suspected pulmonary embolism

– Headache (traumatic and non-traumatic)

– Hip pain

– Low back pain

– Shoulder pain (to include suspected rotator cuff injury)

– Cancer of the lung (primary or metastatic, suspected or diagnosed)

– Cervical or neck pain

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• CDSM Qualifications and Requirements– Interactive, electronic tool for use by clinicians that communicates

AUC information to the user and assists them in making the most appropriate treatment decision for a patient’s specific clinical condition

– Will incorporate specified applicable AUC sets from which an ordering professional could select

– Module within or available through certified EHR technology or private sector mechanisms independent from certified EHR technology

• If incorporated into the EHR relevant patient –specific information will be included in the assessment

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• CDSM Application Process– CDSM developers are currently challenged with meeting an

application deadline of January 1, 2017

– Therefore, the application process deadline has been extended to March 1, 2017

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PROHIBITION ON BILLING QUALIFIED MEDICARE

BENEFICIARY INDIVIDUALS FOR MEDICARE COST-

SHARING

12/9/2016 148

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Prohibition Reminder

• Collection of Medicare Part A and Medicare Part B deductibles, coinsurance, or copayments, from beneficiaries enrolled in the Qualified Medicare Beneficiaries (QMB) program is prohibited by Federal law– Needed reeducation of providers regarding proper billing practices of

QMB enrollees

– Information on how to identify a QMB patient can be found at the following:

• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/downloads/se1128.pdf

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/downloads/se1128.pdf

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Prohibition Reminder

• Medicare providers must accept the Medicare payment and Medicaid payment (if any, and including any permissible Medicaid cost sharing from the beneficiary) as payment in full for services rendered to a QMB individual

• Providers who violate these billing prohibitions are violating their Medicare Provider Agreement and may be subject to sanctions

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JW MODIFIER

12/9/2016 151

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CY 2017 CPT CODE UPDATES

12/9/2016 152

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CY 2017 CPT CODE UPDATES

AGENDA

Code Changes:• Surgery• Radiology• Laboratory• Medicine

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2017 CPT: SUMMARY BY DEPARTMENT

12/9/2016 154

Section Additions Revisions

Deletions

Total

E/M (99201-99499) 0 0 1 1Integumentary (10021-19499) 0 0 1 1Musculoskeletal (20005-29999) 11 8 8 27Respiratory (30000-32999) 9 8 2 19Cardiovascular (33010-39599) 19 3 14 36Digestive (40490-49999) 2 0 0 2Urinary/Genital (50010-59899) 1 0 0 1Nervous-Eye-Ear (61000-69990) 9 3 4 16Radiology (70010-79999) 4 2 11 17Path/Laboratory (80047-89398) 11 6 8 25Medicine (90281-99607) 26 30 14 70Category II (0001F-7025F) 0 1 0 1

Category III (0019T-0290T) 56 2 17 75

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2017 Manual Changes

• Missing Appendix!– Appendix G has been removed

• Deleted Symbols– Moderate sedation symbol removed

• New Symbols– Telehealth medicine code– Moderate sedation removed from the procedure

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CY 2017 CPT Code Update: Manual

• New Modifier – Modifier 95– Telehealth Services

• New Place-of-Service Codes (Professional Claims)– 18: Place of Employment – Worksite

(provides on-going or episodic occupational medical, therapeutic or rehabilitative services)

– 19: Unassigned

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2017 CPT: SUMMARY BY DEPARTMENT

12/9/2016 157

●

▲

Code Symbols

New Code

Revised Code

D Deleted Code

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CY 2017 CPT Changes

12/9/2016 158

Action CPT Description Replacement

D 11752Excision of nail and nail matrix, partial or complete (eg, ingrown or deformed nail), for permanent removal; with amputation of tuft of distal phalanx

262362812426160

Integumentary System

26236 - Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis); distal phalanx of finger

28124 - Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (eg, osteomyelitis or bossing); phalanx of toe

26160 - Excision of lesion of tendon sheath or joint capsule (eg, cyst, mucous cyst, or ganglion), hand or finger

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Integumentary System

Although not new….• CPT 10160 – puncture aspiration of abscess, heamtoma,

bulla or cyst– If imaging guidance is performed, see 76942, 77002, 77012, 77021

• CPT 11750 - Excision of nail and nail matrix, partial or complete (eg, ingrown or deformed nail), for permanent removal– Now a stand alone code – no longer an add on code for 2017

• CPT +15777 – Implantation of biogical implant– For implantation of non-biologic or synthetic implant for fascial

reinforcement of the abdominal wall, use 0437T

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CY 2017 CPT Changes- Integumentary System

• Destruction of Benign or Premalignant Lesions

• CPT 17110-17111 – For destruction of extensive cutaneous neurofibroma over 50-100

lesions, see 0419T, 0420T• 0419T – Destruction neurofibromata, extensive, (cutaneous, dermal extending into

subcutaneous); face, head and neck, greater than 50 neurofibromata

• 0420T - Destruction neurofibromata, extensive,

12/9/2016 160

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CY 2017 CPT Change – Musculoskeletal System

12/9/2016 161

Action CPT Description

▲ 20240

Biopsy, bone, open; superficial (eg, ilium sternum, spinous process, rib, patella, spinous olecranon process, calcaneus, tarsal, metatarsal, trochanter of femur carpal, metacarpal, phalanx)

▲ 20245Biopsy, bone, open; deep (eg, humerus humeral shaft, ischium, femur femoral shaft)

Musculoskeletal System

Code descriptors revised to to delineate the anatomical sites most likely to correspond a deep bone biopsy

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CY 2017 CPT Changes – Musculoskeletal System

12/9/2016 162


D 21495 Open treatment of hyoid fracture; ▲31584

D 22305 Closed treatment of vertebral process fracture(s)See E& M

codes

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12/9/2016 163


D 22851

Application of intervertebral biomechanical device(s) (eg, synthetic cage(s), methylmethacrylate) to vertebral defect or interspace (List separately in addition to code for primary procedure)

●22853●22854●22859

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12/9/2016 164


● +22853

Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace

● +22854

Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to vertebral corpectomy(ies) (vertebral body resection, partial or complete) defect, in conjunction with interbody arthrodesis, each contiguous defect

● +22859Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh, methylmethacrylate) to intervertebral disc space or vertebral body defect without interbody arthrodesis, each contiguous defect

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• Musculoskeletal – Spinal Instrumentation– CPT codes 22853, 22854, and 22859 are to be reported once for each

contiguous defect– Parenthetical note indicates they may be reported once for each non-

contiguous defect– Reminder:

• Instrumentation is reported in addition to the arthrodesis procedure• Modifier 62 may not be appended to the definitive or add-on spinal instrumentation

procedure code(s) 22840-22848, 22850, 22852, 22853, 22854, 22859.

12/9/2016 165

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CY 2017 CPT Changes - Musculoskeletal

12/9/2016 166


● 22867Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; single level

● +22868Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; second level

● 22869Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level

● +22870Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level

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• 22867, 22868, 22869, and 22870– Imaging guidance is included– CPT codes 22868 and 22870 are add on codes to be reported for the

instrumentation completed at the second level– Thse codes are not to be reported with other spinal procedures reported for

the same level

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12/9/2016 168


D 27193Closed treatment of pelvic ring fracture, dislocation, diastasis or subluxation; without manipulation

●27197

D 27194

Closed treatment of pelvic ring fracture, dislocation, diastasis or subluxation; with manipulation, requiring more than local anesthesia (ie, general anesthesia, moderate sedation, spinal/epidural)

●27198

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CY 2017 CPT Changes – Musculoskeletal

12/9/2016 169


● 27197

Closed treatment of posterior pelvic ring fracture(s), dislocation(s), diastasis or subluxation of the ilium, sacroiliac joint, and/or sacrum, with or without anterior pelvic ring fracture(s) and/or dislocation(s) of the pubic symphysis and/or superior/inferior rami, unilateral or bilateral; without manipulation

● 27198

Closed treatment of posterior pelvic ring fracture(s), dislocation(s), diastasis or subluxation of the ilium, sacroiliac joint, and/or sacrum, with or without anterior pelvic ring fracture(s) and/or dislocation(s) of the pubic symphysis and/or superior/inferior rami, unilateral or bilateral; with manipulation, requiring more than local anesthesia (ie, general anesthesia, moderate sedation, spinal/epidural)

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12/9/2016 170


▲ 28289Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint; without implant

D 28290Correction, hallux valgus (bunion), with or without sesamoidectomy; simple exostectomy (eg, Silver type procedure)

▲28292

● 28291Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint; with implant

▲ 28292

Correction, hallux valgus (bunion)(bunionectomy), with or without sesamoidectomy, when performed; Keller, McBride with resection of proximal phalanx base, or Mayo type procedure when performed, any method

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12/9/2016 171


D 28293Correction of hallux valgus (bunion), with or without sesamoidectomy; resection of joint with implant

●28291

D 28294Correction of hallux valgus (bunion), with or without sesamoidectomy; with tendon transplants (eg, Joplin type procedure)

28899

● #28295Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with proximal metatarsal osteotomy, any method

▲ 28296

Correction, hallux valgus (bunion)(bunionectomy), with or without sesamoidectomy, when performed; with distal metatarsal osteotomy, (eg, Mitchell, Chevron, or concentric type procedures)any method

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12/9/2016 172


▲ 28297Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; Lapidus-type procedure with first metatarsal and medial cuneiform joint arthrodesis, any method

▲ 28298Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; by with proximal phalanx osteotomy, any method

▲ 28299Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; by with double osteotomy, any method

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CY 2017 CPT Changes - Respiratory

• Endoscopy Guideline Changes p 177– For endoscopic procedures, report appropriate endoscopy of each anatomic

site examined. Laryngoscopy includes examination of the tongue base, larynx, and hypopharynx. The anatomic structures examined with this procedure include both midline (single anatomic sites) and paired structures. Midline, single anatomic sites include tongue base, vallecula, epiglottis, subglottis, and posterior pharyngeal wall. Paired structures include true vocal cords, arytenoids, false vocal cords, ventricles, pyriform sinuses, and aryepiglottic folds. For the purposes of reporting therapeutic interventions, all paired structures contained within one side of the larynx/pharynx are considered unilateral. If using operating microscope, telescope, or both, use the applicable code only once per operative session.

12/9/2016 173

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12/9/2016 174


● #31551Laryngoplasty; for laryngeal stenosis, with graft, without indwelling stent placement, younger than 12 years of age

● #31552Laryngoplasty; for laryngeal stenosis, with graft, without indwelling stent placement, age 12 years or older

● #31553Laryngoplasty; for laryngeal stenosis, with graft, with indwelling stent placement, younger than 12 years of age

● #31554Laryngoplasty; for laryngeal stenosis, with graft, with indwelling stent placement, age 12 years or older

● #31572Laryngoscopy, flexible; with ablation or destruction of lesion(s) with laser, unilateral

● #31573Laryngoscopy, flexible; with therapeutic injection(s) (eg, chemodenervation agent or corticosteroid, injected percutaneous, transoral, or via endoscope channel), unilateral

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CY 2017 CPT Changes – Respiratory

12/9/2016 175


● #31574Laryngoscopy, flexible; with injection(s) for augmentation (eg, percutaneous, transoral), unilateral

▲ 31575 Laryngoscopy, flexible fiberoptic; diagnostic

▲ 31576 Laryngoscopy, flexible fiberoptic ; with biopsy(ies)

▲ 31577 Laryngoscopy, flexible fiberoptic; with removal of foreign body(s)

▲ 31578 Laryngoscopy, flexible fiberoptic; with removal of lesion(s), non-laser

▲ 31579 Laryngoscopy, flexible or rigid fiberoptic telescopic, with stroboscopy

▲ 31580Laryngoplasty; for laryngeal web, 2-stage, with indwelling keel insertion and removal or stent insertion

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12/9/2016 176


D 31582Laryngoplasty; for laryngeal stenosis, with graft or core mold, including tracheotomy

●31551●31552●31553●31554

▲ 31584Laryngoplasty; with open reduction and fixation of (eg, plating) of fracture, includes tracheostomy, if performed

▲ 31587 Laryngoplasty; cricoid split, without graft placement

D 31588Laryngoplasty, not otherwise specified (eg, for burns, reconstruction after partial laryngectomy)

31599

● 31591 Laryngoplasty, medialization, unilateral

● 31592 Cricotracheal resection

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CY 2017 CPT Changes - Cardiovascular

12/9/2016 177


● 33340

Percutaneous transcatheter closure of the left atrial appendage with endocardial implant, including fluoroscopy, transseptal puncture, catheter placement(s), left atrial angiography, left atrial appendage angiography, when performed, and radiological supervision and interpretation

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12/9/2016 178


● 33390Valvuloplasty, aortic valve, open, with cardiopulmonary bypass; simple (ie, valvotomy, debridement, debulking, and/or simple commissural resuspension)

● 33391Valvuloplasty, aortic valve, open, with cardiopulmonary bypass; complex (eg, leaflet extension, leaflet resection, leaflet reconstruction, or annuloplasty)

D 33400Valvuloplasty, aortic valve; open, with cardiopulmonary bypass

●33390●33391

D 33401 Valvuloplasty, aortic valve; Open, witth inflow occlusion●33390●33391

D 33403Valvuloplasty, aortic valve; using transventricular dilation, with cardiopulmonary bypass

●33390●33391

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12/9/2016 179


▲ 33405Replacement, aortic valve, open, with cardiopulmonary bypass; with prosthetic valve other than homograft or stentless valve

▲ 33406Replacement, aortic valve, open, with cardiopulmonary bypass; with allograft valve (freehand)

▲ 33410Replacement, aortic valve, open, with cardiopulmonary bypass; with prosthetic valve other than homograft or stentless valve with stentless tissue valve

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CY 2017 CPT Changes Cardiovascular

12/9/2016 180


D 35450Transluminal balloon angioplasty, open; renal or other visceral artery

●36902●36905●36907●37246●37247

D 35452 Transluminal balloon angioplasty, open; aortic

●36902●36905●36907●37246●37247

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12/9/2016 181


D 35458Transluminal balloon angioplasty, open; brachiocephalic trunk or branches, each vessel

●36902●36905●36907●37246●37247

D 35460 Transluminal balloon angioplasty, open; venous

●36902●36905●36907●37248●37249

D 35471Transluminal balloon angioplasty, percutaneous; renal or visceral artery

●36902●36905●36907●37246●37247

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CY 2017 CPT Changes Cardiovascular

12/9/2016 182


D 35472 Transluminal balloon angioplasty, percutaneous; aortic

●36902●36905●36907●37246●37247

D 35475Transluminal balloon angioplasty, percutaneous; brachiocephalic trunk or branches, each vessel

●36902●36905●36907●37246●37247

D 35476 Transluminal balloon angioplasty, percutaneous; venous

●36902●36905●36907●37248●37249

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CY 2017 CPT Changes

12/9/2016 183


D 36147

Introduction of needle and/or catheter, arteriovenous shunt created for dialysis (graft/fistula); initial access with complete radiological evaluation of dialysis access, including fluoroscopy, image documentation and report…

●36901●36902●36903●36904●36905●36906

D +36148Introduction of needle and/or catheter, arteriovenous shunt created for dialysis (graft/fistula); additional access for therapeutic intervention

●36901●36902●36903●36904●36905●36906

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12/9/2016 184


● 36456Partial exchange transfusion, blood, plasma or crystalloid necessitating the skill of a physician or other qualified health care professional, newborn

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12/9/2016 185


● 36473Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; first vein treated

● +36474

Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure)

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2017 CPT Changes – Cardiovascular

• Dialysis Circuit Codes – 36901-36909– New codes established for 2017– Deletion of CPT code 36870– Guidelines p 245-247– Codes include imaging guidance; however, not all codes include

ultrasound• CPT codes 36901, 36902, 36903, 36904, 36905, and 36906 do not incule

ultraound guidance; therefore, CPT code 76937 may be separately reported if all appropriate elements for reporting 76937 are performed and documented

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12/9/2016 187


● 36901

Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s), injection(s) of contrast, all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava, fluoroscopic guidance, radiological supervision and interpretation and image documentation and report;

● 36902; with transluminal balloon angioplasty, peripheral dialysis segment, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty

● 36903

; with transcatheter placement of intravascular stent(s), peripheral dialysis segment, including all imaging and radiological supervision and interpretation necessary to perform the stenting, and all angioplasty within the peripheral dialysis segment

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12/9/2016 188



• CPT code 36902 Includes:• Balloon angioplasty performed in the peripheral segment of

dialysis circuit, regardless of the number of lesions treated in the peripheral segment, the number of times the balloon is inflated, the number of balloon catheters or their size

• Angioplasty of the peri-anastomotic segment when performed

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12/9/2016 189


● 36903

; with transcatheter placement of intravascular stent(s), peripheral dialysis segment, including all imaging and radiological supervision and interpretation necessary to perform the stenting, and all angioplasty within the peripheral dialysis segment

• CPT 36903 Includes:• Transcather stent placemnt in the peripheral segment of the dialysis circuit

• Reported only once per session , regardless of the number of stents placed or lesions treated within the peripheral segment.

• When both angioplasty and stenting are performed, only report the stenting (CPT 36903) and only once

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2017 CPT Changes – Cardiovascular 2017 CPT Changes – Cardiovascular

12/9/2016 190


● 36904

Percutaneous transluminal mechanical thrombectomy and/or infusion for thrombolysis, dialysis circuit, any method, including all imaging and radiological supervision and interpretation, diagnostic angiography, fluoroscopic guidance, catheter placement(s), and intraprocedural pharmacological thrombolytic injection(s);

• CPT 36904 Includes:• Percutansious transluminal mechanical thrombecomy and/or infusion for

thrombolysis in the dialysis circuit - thrombus in the peripheral and central dialysis circuit segment.

• All intraprocedural pharmacologic thrombolytic injections or infusions• Do not report for the removal of the arterial plug as it is included in a fistula

thrombectomy.

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CY 2017 CPT Changes – Cardiovascular

12/9/2016 191



CPT 36905 Includes:• All services in 36904 when performed with thrombylisis and/thrombectomy

plus angioplasty when perfomred in the peripheral segment of the circuit. • CPT 36905 is only reported once per session to describe all angioplasty

performed regardless of the number of lesions treated, number of times the balloon is inflated or the number of catheters required to achieve patency.

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CY 2017 CPT Changes – Cardiovascular

12/9/2016 192


● 36906

; with transcatheter placement of intravascular stent(s), peripheral dialysis segment, including all imaging and radiological supervision and interpretation necessary to perform the stenting, and all angioplasty within the peripheral dialysis circuit

• CPT 36906 include all services in 36905 when performed with transcather stent placement when performed in the peripheral segment of the circuit.

• 36906 is only reported once per session to describe all stent placements within the peripheral segment regardless of the number of stents placed or lesions treated

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CY 2017 CPT Changes

12/9/2016 193


● +36907Transluminal balloon angioplasty, central dialysis segment, performed through dialysis circuit, including all imaging and radiological supervision and interpretation required to perform the angioplasty

● +36908

Transcatheter placement of intravascular stent(s), central dialysis segment, performed through dialysis circuit, including all imaging radiological supervision and interpretation required to perform the stenting, and all angioplasty in the central dialysis segment

●+36909

Dialysis circuit permanent vascular embolization or occlusion (including main circuit or any accessory veins), endovascular, including all imaging and radiological supervision and interpretation necessary to complete the intervention

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CY 2017 CPT Changes – Cardiovascular Changes

• Endovascular Revascularization – CPT codes 37246-37429– CPT 37247 and 37246

• Open, percuntaneous, or transcatheter arterial balloon angioplasty – Excludes:

» Central nervous system» Coronary» Pulmonary» Lower extremities for occulsuve disease

• Includes imaging guidance

12/9/2016 194

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12/9/2016 195


● #37246

Transluminal balloon angioplasty (except lower extremity artery(ies) for occlusive disease, intracranial, coronary, pulmonary, or dialysis circuit), open or percutaneous, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty within the same artery; initial artery

● #+37247

Transluminal balloon angioplasty (except lower extremity artery(ies) for occlusive disease, intracranial, coronary, pulmonary, or dialysis circuit), open or percutaneous, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty within the same artery; each additional artery

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• Endovascular Revascularization – CPT codes 37246-37429– CPT 37248 and 37249

• Open, percuntaneous, or transcatheter venous balloon angioplasty – Excludes Dialysis Circuit

• Include imaging guidance• Inherent to stenting in the extracranial carotid and innominate arteries and

therfore not separately reportable when performed• Reported only once for multiple lesions in the same vessel

– If the lesion begins in one vessel and extends into another it is still reported once

12/9/2016 196

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CY 2017 CPT Changes

12/9/2016 197


● #37248

Transluminal balloon angioplasty (except dialysis circuit), open or percutaneous, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty within the same vein; initial vein

● #+37249

Transluminal balloon angioplasty (except dialysis circuit), open or percutaneous, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty within the same vein; each additional vein

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• Endovascular Revascularization – CPT codes 37246-37429– When additional, separate, and distinct ipsilateral and contralateral

vessels are treated in the same session 37247 and 37249 may be reported separately

– Non-selective and selective cathertization are separately reportable– Radiologcal supervision and interpretation are included when directly

related to the intervention– Imaging used to document completion is also included– Extensive repair or replacement is separately reported– Mechanical thrombectomy and/or thrombolytic therapy is separately

reported

12/9/2016 198

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CY 2017 CPT Changes - Digestive

12/9/2016 199


● 43284Laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device (ie, magnetic band), including cruroplasty when performed

● 43285 Removal of esophageal sphincter augmentation device

CPT codes 43284 and 43285 are not to be reported with other fundoplasty procedures (43279,43280,43281, and 43282)

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CY 2017 CPT Changes – Female Genital System

12/9/2016 200


● 58674Laparoscopy, surgical, ablation of uterine fibroid(s) including intraoperative ultrasound guidance and monitoring, radiofrequency

• CPT code 58674 includes the ultrasound guidance and radiofrequency monitoring• Parenthetical note on p 79. indicates this service should not to be reported with

CPT codes 49320, 58541-58554, 58570, 58570, 58572, 58573, and 76998

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CY 2017 CPT Changes – Nervous System

12/9/2016 201


▲ 62287

Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, any method utilizing needle based technique to remove disc material under fluoroscopic imaging or other form of indirect visualization, with the use of an endoscope, with discography and/or epidural injection(s) at the treated level(s), when performed, single or multiple levels, lumbar

D 62310

Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement,…; cervical or thoracic

●62320

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CY 2017 CPT Changes

12/9/2016 202


D 62311

Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; lumbar or sacral (caudal)

●62322

D 62318

Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, includes contrast for localization when performed, epidural or subarachnoid; cervical or thoracic

●62324

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CY 2017 CPT Changes

12/9/2016 203


D 62319

Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, includes contrast for localization when performed, epidural or subarachnoid; lumbar or sacral (caudal)

●62326

● 62320

Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance

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CY 2017 CPT Changes

12/9/2016 204


● 62321

Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance

● 62322

Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance

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CY 2017 CPT Changes

12/9/2016 205


● 62323

Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT)

● 62324

Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance

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CY 2017 CPT Changes

12/9/2016 206


● 62325

Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT)

● 62326

Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance

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CY 2017 CPT Changes

12/9/2016 207


● 62327

Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT)

● 62380Endoscopic decompression of spinal cord, nerve root(s), including laminotomy, partial facetectomy, foraminotomy, discectomy and/or excision of herniated intervertebral disc, 1 interspace, lumbar

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CY 2017 CPT Changes – Eye and Occular System

12/9/2016 208


▲ 67101Repair of retinal detachment, 1 or more sessions including drainage of subretinal fluid when performed; cryotherapy or diathermy, including drainage of subretinal fluid, when performed

▲ 67105Repair of retinal detachment, 1 or more sessions including drainage of subretinal fluid when performed; photocoagulation, including drainage of subretinal fluid, when performed

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CY 2017 CPT Changes – Imaging Services

12/9/2016 209


D 75791

Angiography, arteriovenous shunt (eg, dialysis patient fistula/graft), complete evaluation of dialysis access, including fluoroscopy, image documentation and report (includes injections of contrast and all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava), radiological supervision and interpretation

●36901●36902●36903●36904●36905●36906

D 75962Transluminal balloon angioplasty, peripheral artery other than renal, or other visceral artery, iliac or lower extremity, radiological supervision and interpretation

●36902●36905●37246

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12/9/2016 210


D +75964

Transluminal balloon angioplasty, each additional peripheral artery other than renal or other visceral artery, iliac or lower extremity, radiological supervision and interpretation

●36902●36905●37247

D 75966Transluminal balloon angioplasty, renal or other visceral artery, radiological supervision and interpretation

●36902●36905●37246

D +75968Transluminal balloon angioplasty, each additional visceral artery, radiological supervision and interpretation

●36902●36905●37247

D 75978Transluminal balloon angioplasty, venous (eg, subclavian stenosis), radiological supervision and interpretation

●36902●36905●36907●37248●37249

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12/9/2016 211


● 76706Ultrasound, abdominal aorta, real time with image documentation, screening study for abdominal aortic aneurysm (AAA)

▲ +77002Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device) (new add-on)

▲ +77003

Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid) (new add-on)

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12/9/2016 212


D +77051

Computer-aided detection (computer algorithm analysis of digital image data for lesion detection) with further review for interpretation, with or without digitization of film radiographic images; diagnostic mammography

●77065●77066

D +77052

Computer-aided detection (computer algorithm analysis of digital image data for lesion detection) with further review for interpretation, with or without digitization of film radiographic images; screening mammography

●77067

D 77055 Mammography; unilateral ●77065

D 77056 Mammography; bilateral ●77066

D 77057Screening mammography, bilateral (2-view study of each breast)

●77067

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CY 2017 CPT Changes - Imaging Services

12/9/2016 213


● 77065Diagnostic mammography, including computer-aided detection(CAD) when performed;unilateral

● 77066Diagnostic mammography, including computer-aided detection (CAD) when performed;bilateral

● 77067Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed

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CY 2017 CPT Changes – Pathology and Lab

12/9/2016 214


D 80300

Drug screen, any number of drug classes from Drug Class List A; any number of non-TLC devices or procedures, (eg, immunoassay) capable of being read by direct optical observation, including instrumented-assisted when performed (eg, dipsticks, cups, cards, cartridges), per date of service

●80305●80306

D 80301

Drug screen, any number of drug classes from Drug Class List A; single drug class method, by instrumented test systems (eg, discrete multichannel chemistry analyzers utilizing immunoassay or enzyme assay), per date of service

●80307

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CY 2017 CPT Changes

12/9/2016 215


D 80302

Drug screen, presumptive, single drug class from Drug Class List B, by immunoassay (eg, ELISA) or non-TLC chromatography without mass spectrometry (eg, GC, HPLC), each procedure

●80307

D 80303

Drug screen, any number of drug classes, presumptive, single or multiple drug class method; thin layer chromatography procedure(s) (TLC) (eg, acid, neutral, alkaloid plate), per date of service

●80307

D 80304

Drug screen, any number of drug classes, presumptive, single or multiple drug class method; not otherwise specified presumptive procedure (eg, TOF, MALDI, LDTD, DESI, DART), each procedure

●80307

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12/9/2016 216


● 80305

Drug test(s), presumptive, any number of drug classes, any number of devices or procedures (eg, immunoassay); capable of being read by direct optical observation only (eg, dipsticks, cups, cards, cartridges) includes sample validation when performed, per date of service

● 80306

Drug test(s), presumptive, any number of drug classes, any number of devices or procedures (eg, immunoassay); read by instrument assisted direct optical observation (eg, dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of service

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12/9/2016 217


● 80307

Drug test(s), presumptive, any number of drug classes, any number of devices or procedures, by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service

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12/9/2016 218


D 81280Long QT syndrome gene analyses (eg, KCNQ1, KCNH2, SCN5A, KCNE1, KCNE2, KCNJ2, CACNA1C, CAV3, SCN4B, AKAP, SNTA1, and ANK2); full sequence analysis

●81413

D 81281Long QT syndrome gene analyses (eg, KCNQ1, KCNH2, SCN5A, KCNE1, KCNE2, KCNJ2, CACNA1C, CAV3, SCN4B, AKAP, SNTA1, and ANK2); known familial sequence variant

●81413

D 81282Long QT syndrome gene analyses (eg, KCNQ1, KCNH2, SCN5A, KCNE1, KCNE2, KCNJ2, CACNA1C, CAV3, SCN4B, AKAP, SNTA1, and ANK2); duplication/deletion variants

●81414

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12/9/2016 219


● 81327 SEPT9 (Septin9) (eg, colorectal cancer) methylation analysis

▲ 81401

Molecular pathology procedure, Level 2 (eg, 2-10 SNPs, 1 methylated variant, or 1 somatic variant [typically using nonsequencing target variant analysis], or detection of a dynamic mutation disorder/triplet repeat) SEPT9 (septin 9) (eg, colon cancer), methylation analysis

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12/9/2016 220


▲ 81403

Molecular pathology procedure, Level 4 (eg, analysis of single exon by DNA sequence analysis, analysis of >10 amplicons using multiplex PCR in 2 or more independent reactions, mutation scanning or duplication/deletion variants of 2-5 exons) Killer cell immunoglobulin-like receptor (KIR) gene family (eg, hematopoietic stem cell transplantation), genotyping of KIR family genes Known familial variant not otherwise specified, for gene listed in Tier 1 or Tier 2, or identified during a genomic sequencing procedure, DNA sequence analysis, each variant exon

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12/9/2016 221


▲ 81406

Molecular pathology procedure, Level 7 (eg, analysis of 11-25 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of 26-50 exons, cytogenomic array analysis for neoplasia)KCNH2 (potassium voltage-gated channel, subfamily H [eag-related], member 2) (eg, short QT syndrome, long QT syndrome), full gene sequence(Do not report 81406 for KCNH2 full gene sequence in conjunction with 81280) KCNQ1 (potassium voltage-gated channel, KQT-like subfamily, member 1) (eg, short QT syndrome, long QT syndrome), full gene sequence(Do not report 81406 for KCNQ1 full gene sequence with 81280)

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● 81413

Cardiac ion channelopathies (eg, Brugada syndrome, long QT syndrome, short QT syndrome, catecholaminergic polymorphic ventricular tachycardia); genomic sequence analysis panel, must include sequencing of at least 10 genes, including ANK2, CASQ2, CAV3, KCNE1, KCNE2, KCNH2, KCNJ2, KCNQ1, RYR2, and SCN5A

● 81414

Cardiac ion channelopathies (eg, Brugada syndrome, long QT syndrome, short QT syndrome, catecholaminergic polymorphic ventricular tachycardia); duplication/deletion gene analysis panel, must include analysis of at least 2 genes, including KCNH2 and KCNQ1

● 81422Fetal chromosomal microdeletion(s) genomic sequence analysis (eg, DiGeorge syndrome, Cri-du-chat syndrome), circulating cell-free fetal DNA in maternal blood

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● 81439

Inherited cardiomyopathy (eg, hypertrophic cardiomyopathy, dilated cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy) genomic sequence analysis panel, must include sequencing of at least 5 genes, including DSG2, MYBPC3, MYH7, PKP2, and TTN

● 81539Oncology (high-grade prostate cancer), biochemical assay of four proteins (Total PSA, Free PSA, Intact PSA, and human kallikrein-2 [hK2]), utilizing plasma or serum, prognostic algorithm reported as a probability score

▲ 83015Heavy metal (eg, arsenic, barium, beryllium, bismuth, antimony, mercury); screen qualitative, any number of analytes

▲ 83018Heavy metal (eg, arsenic, barium, beryllium, bismuth, antimony, mercury); quantitative, each, not elsewhere specified

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12/9/2016 224


▲ 83704

Heavy metal (eg, arsenic, barium, beryllium, bismuth, antimony, mercury); quantitation of lipoprotein particle numbers and lipoprotein particle subclasses number(s) (eg, by nuclear magnetic resonance spectroscopy), includes lipoprotein particle subclass(es), when performed

● 84410Testosterone; bioavailable, direct measurement (eg, differential precipitation)

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12/9/2016 225


● 87483

Infectious agent detection by nucleic acid (DNA or RNA); central nervous system pathogen (eg, Neisseria meningitidis, Streptococcus pneumoniae, Listeria, Haemophilus influenzae, E. coli, Streptococcus agalactiae, enterovirus, human parechovirus, herpes simplex virus type 1 and 2, human herpesvirus 6, cytomegalovirus, varicella zoster virus, Cryptococcus), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 12-25 targets

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CY 2017 CPT Changes – Medicine

12/9/2016 226


▲ #90644

Meningococcal conjugate vaccine, serogroups C & Y and Haemophilus influenzae type b vaccine (Hib-MenCY), 4 dose schedule, when administered to children 2 6 weeks-18 months of age, for intramuscular use

▲ 90655Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, when administered to children 6-35 months of age 0.25 mL dosage, for intramuscular use

▲ 90656Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, when administered to individuals 3 years and older 0.5 mL dosage, for intramuscular use

▲ 90657Influenza virus vaccine, trivalent (IIV3), split virus, when administered to children 6-35 months of age 0.25 mL dosage, for intramuscular use

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12/9/2016 227


▲ 90658Influenza virus vaccine, trivalent (IIV3), split virus, when administered to individuals 3 years of age and older 0.5 mL dosage, for intramuscular use

▲ 90661Influenza virus vaccine, trivalent (ccIIV3), derived from cell cultures, subunit, preservative and antibiotic free, 0.5 mL dosage, for intramuscular use

● 90674Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, preservative and antibiotic free, 0.5 mL dosage, for intramuscular use

▲ 90685Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, when administered to children 6-35 months of age 0.25 mL dosage, for intramuscular use

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12/9/2016 228


▲ 90686Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free,when administered to individuals 3 years of age and older 0.5 mL dosage, for intramuscular use

▲ 90687Influenza virus vaccine, quadrivalent (IIV4), split virus, when administered to children 6-35 months of age 0.25 mL dosage, for intramuscular use

▲ 90688Influenza virus vaccine, quadrivalent (IIV4), split virus, when administered to individuals 3 years of age and older 0.5 mL dosage, for intramuscular use

▲ 90734Meningococcal conjugate vaccine, serogroups A, C, Y and W-135, quadrivalent (MenACWY) (MCV4 or MenACWY), for intramuscular use

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12/9/2016 229


▲ 90832 Psychotherapy, 30 minutes with patient and/or family member

▲ +90833Psychotherapy, 30 minutes with patient and/or family member when performed with an evaluation and management service





▲ 90846 Family psychotherapy (without the patient present), 50 minutes

▲ 90847Family psychotherapy (conjoint psychotherapy) (with patient present), 50 minutes

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• Psychiatric Collaborative Care Management Services (COCM)– Feb. 2016: AMA created 3 new codes to describe the provision of psychiatric

care in the primary care setting– Apr. 2016: Specialty societies requested this issue to be deferred– CY 2017 Medicare Physician Fee Schedule Final Rule:

• Established 3 new G-codes• Information sharing between PCP and a specialist• Codes temporary (1 year)

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12/9/2016 231


● G0502

Initial psychiatric collaborative care management, first 70 minutes in the first calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional, with the following required elements: outreach to and engagement in treatment of a patient directed by the treating physician or other qualified health care professional; initial assessment of the patient, including administration of validated rating scales, with the development of an individualized treatment plan; review by the psychiatric consultant with modifications of the plan if recommended; entering patient in a registry and tracking patient follow-up and progress using the registry, with appropriate documentation, and participation in weekly caseload consultation with the psychiatric consultant; and provision of brief interventions using evidence-based techniques such as behavioral activation, motivational interviewing, and other focused treatment strategies

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12/9/2016 232


● G0503

Subsequent psychiatric collaborative care management, first 60 minutes in a subsequent month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional, with the following required elements: tracking patient follow-up and progress using the registry, with appropriate documentation; participation in weekly caseload consultation with the psychiatric consultant; ongoing collaboration with and coordination of the patient's mental health care with the treating physician or other qualified health care professional and any other treating mental health providers; additional review of progress and recommendations for changes in treatment, as indicated, including medications, based on recommendations provided by the psychiatric consultant; provision of brief interventions using evidence-based techniques such as behavioral activation, motivational interviewing, and other focused treatment strategies; monitoring of patient outcomes using validated rating scales; and relapse prevention planning with patients as they achieve remission of symptoms and/or other treatment goals and are prepared for discharge from active treatment

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12/9/2016 233


● G0504

Initial or subsequent psychiatric collaborative care management, each additional 30 minutes in a calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional (list separately in addition to code for primary procedure); (use G0504 in conjunction with G0502, G0503)

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12/9/2016 234


D 92140Provocative tests for glaucoma, with interpretation and report, without tonography

▲ 92235Fluorescein angiography (includes multiframe imaging) with interpretation and report, unilateral or bilateral

▲ 92240Indocyanine-green angiography (includes multiframe imaging) with interpretation and report, unilateral or bilateral

● 92242Fluorescein angiography and indocyanine-green angiography (includes multiframe imaging) performed at the same patient encounter with interpretation and report, unilateral or bilateral

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12/9/2016 235


▲ 92612Flexible fiberoptic endoscopic evaluation of swallowing by cine or video recording;

▲ 92613Flexible fiberoptic endoscopic evaluation of swallowing by cine or video recording; interpretation and report only

▲ 92614Flexible fiberoptic endoscopic evaluation, laryngeal sensory testing by cine or video recording;

▲ 92615Flexible fiberoptic endoscopic evaluation, laryngeal sensory testing by cine or video recording; interpretation and report only

▲ 92616Flexible fiberoptic endoscopic evaluation of swallowing and laryngeal sensory testing by cine or video recording;

▲ 92617Flexible fiberoptic endoscopic evaluation of swallowing and laryngeal sensory testing by cine or video recording; interpretation and report only

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12/9/2016 236


▲ +92978

Intravascular ultrasound (Endoluminal imaging of coronary vessel or graft)using intravascular ultrasound (IVUS) or optical coherence tomography (OCT) during diagnostic evaluation and/or therapeutic intervention including imaging supervision, interpretation and report; initial vessel

▲ +92979

Intravascular ultrasound (Endoluminal imaging of coronary vessel or graft) using intravascular ultrasound (IVUS) or optical coherence tomography (OCT) during diagnostic evaluation and/or therapeutic intervention including imaging supervision, interpretation and report; each additional vessel

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12/9/2016 237


● 93590Percutaneous transcatheter closure of paravalvular leak; initial occlusion device, mitral valve

● 93591Percutaneous transcatheter closure of paravalvular leak; initial occlusion device, aortic valve

● +93592Percutaneous transcatheter closure of paravalvular leak; each additional occlusion device

D 93965Noninvasive physiologic studies of extremity veins, complete bilateral study (eg, Doppler waveform analysis with responses to compression and other maneuvers, phleborheography, impedance plethysmography

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12/9/2016 238


● 96160Administration of patient-focused health risk assessment instrument (eg, health hazard appraisal) with scoring and documentation, per standardized instrument

● 96161Administration of caregiver-focused health risk assessment instrument (eg, depression inventory) for the benefit of the patient, with scoring and documentation, per standardized instrument

● 96377Application of on-body injector (includes cannula insertion) for timed subcutaneous injection

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12/9/2016 239


D 97001 Physical therapy evaluation ●97161, ●97162, ●97163

D 97002 Physical therapy re-evaluation ●97164

D 97003 Occupational therapy evaluation ●97165, ●97166, ●97167

D 97004 Occupational therapy re-evaluation ●97168

D 97005 Athletic training evaluation ●97169, ●97170, ●97171

D 97006 Athletic training re-evaluation ●97172

Physical Medicine

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12/9/2016 240


● #97161

Physical therapy evaluation: low complexity, requiring these components:● A history with no personal factors and/or comorbidities that impact the plan of care;● An examination of body system(s) using standardized tests and measures addressing 1-2 elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions;● A clinical presentation with stable and/or uncomplicated characteristics; and● Clinical decision making of low complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome.Typically, 20 minutes are spent face-to-face with the patient and/or family.

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12/9/2016 241


● #97162

Physical therapy evaluation: moderate complexity, requiring these components:● A history of present problem with 1-2 personal factors and/or comorbidities that impact the plan of care;● An examination of body systems using standardized tests and measures in addressing a total of 3 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions;● An evolving clinical presentation with changing characteristics; and● Clinical decision making of moderate complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome.Typically, 30 minutes are spent face-to-face with the patient and/or family.

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12/9/2016 242


● #97163

Physical therapy evaluation: high complexity, requiring these components:● A history of present problem with 3 or more personal factors and/or comorbidities that impact the plan of care;● An examination of body systems using standardized tests and measures in addressing a total of 4 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions;● A clinical presentation with unstable and unpredictable characteristics; and● Clinical decision making of high complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome.Typically, 45 minutes are spent face-to-face with the patient and/or family.

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12/9/2016 243


● #97164

Re-evaluation of physical therapy established plan of care, requiring these components:● An examination including a review of history and use of standardized tests and measures is required; and● Revised plan of care using a standardized patient assessment instrument and/or measurable assessment of functional outcomeTypically, 20 minutes are spent face-to-face with the patient and/or family.

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12/9/2016 244


● #97165

Occupational therapy evaluation, low complexity, requiring these components:● An occupational profile and medical and therapy history, which includes a brief history including review of medical and/or therapy records relating to the presenting problem;● An assessment(s) that identifies 1-3 performance deficits (ie, relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and● Clinical decision making of low complexity, which includes an analysis of the occupational profile, analysis of data from problem-focused assessment(s), and consideration of a limited number of treatment options. Patient presents with no comorbidities that affect occupational performance. Modification of tasks or assistance (eg, physical or verbal) with assessment(s) is not necessary to enable completion of evaluation component.Typically, 30 minutes are spent face-to-face with the patient and/or family.

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12/9/2016 245


● #97166

Occupational therapy evaluation, moderate complexity, requiring these components:● An occupational profile and medical and therapy history, which includes an expanded review of medical and/or therapy records and additional review of physical, cognitive, or psychosocial history related to current functional performance:● An assessment(s) that identifies 3-5 performance deficits (ie, relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and● Clinical decision making of moderate complexity, which includes an analysis of the occupational profile, analysis of data from detailed assessment(s), and consideration of several treatment options. Patient presents with comorbidities that affect occupational performance. Minimal to moderate modification of tasks or assistance (eg, physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component.Typically, 45 minutes are spent face-to-face with the patient and/or family.

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12/9/2016 246


● #97167

Occupational therapy evaluation, high complexity, requiring these components:● An occupational profile and medical and therapy history, which includes review of medical and/or therapy records and extensive additional review of physical, cognitive, or psychosocial history related to current functional performance:● An assessment(s) that identifies 5 or more performance deficits (ie, relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and● Clinical decision making of high analytic complexity, which includes an analysis of the patient profile, analysis of data from comprehensive assessment(s), and consideration of multiple treatment options. Patient presents with comorbidities that affect occupational performance. Significant modification of tasks or assistance (eg, physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component.Typically, 60 minutes are spent face-to-face with the patient and/or family.

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12/9/2016 247


● #97168

Re-evaluation of occupational therapy established plan of care, requiring these components:● An assessment of changes in patient functional or medical status with revised plan of care;● An update to the initial occupational profile to reflect changes in condition or environment that affect future interventions and/or goals; and ● A revised plan of care. A formal reevaluation is performed when there is a documented change in functional status or a significant change to the plan of care is required.Typically, 30 minutes are spent face-to-face with the patient and/or family.

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12/9/2016 248


● #97169

Athletic training evaluation, low complexity, requiring these components:● A history and physical activity profile with no comorbidities that affect physical activity;● An examination of affected body area and other symptomatic or related systems addressing 1-2 elements from any of the following: body structures, physical activity, and/or participation deficiencies; and● Clinical decision making of low complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome.Typically, 15 minutes are spent face-to-face with the patient and/or family.

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12/9/2016 249


● #97170

Athletic training evaluation, moderate complexity, requiring these components:● A history and physical activity profile with 1-2 comorbidities that affect physical activity;● An examination of affected body area and other symptomatic or related systems addressing a total of 3 or more elements from any of the following: body structures, physical activity, and/or participation deficiencies; and● Clinical decision making of moderate complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome.Typically, 30 minutes are spent face-to-face with the patient and/or family.

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12/9/2016 250


● #97171

Athletic training evaluation, high complexity, requiring these components:● A history and physical activity profile with 3 or more comorbidities that affect physical activity;● An comprehensive examination of body systems using standardized tests and measures addressing a total of 4 or more elements from any of the following: body structures, physical activity, and/or participation deficiencies;●Clinical presentation with unstable and unpredictable characteristics; and● Clinical decision making of high complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome.Typically, 45 minutes are spent face-to-face with the patient and/or family.

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12/9/2016 251


● #97172

Re-evaluation of athletic training established plan of care requiring these components:● An assessment of patient’s current functional status when there is a documented change; and● A revised plan of care using a standardized patient assessment instrument and/or measurable assessment of functional outcome with an update in management options, goals, and interventions.Typically, 20 minutes are spent face-to-face with the patient and/or family.

▲ 97602

Removal of devitalized tissue from wound(s), non-selective debridement, without anesthesia (eg, wet-to-moist dressings, enzymatic, abrasion, larval therapy), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session

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12/9/2016 252


D 99143

Moderate sedation services …provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports,…; younger than 5 years of age, first 30 minutes intra-service time

●99151●99153

D 99144

Moderate sedation services …provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports…; age 5 years or older, first 30 minutes intra-service time

●99152●99153

Moderate Sedation

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12/9/2016 253


D +99145

Moderate sedation services (other than those services described by codes 00100-01999) provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports,…; each additional 15 minutes intra-service time

●99153

D 99148

Moderate sedation services (other than those services described by codes 00100-01999), provided by a physician or other qualified health care professional other than the health care professional performing the diagnostic or therapeutic service that the sedation supports; younger than 5 years of age, first 30 minutes intra-service time

●99155●99157

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12/9/2016 254


D 99149

Moderate sedation services (other than those services described by codes 00100-01999), provided by a physician or other qualified health care professional other than the health care professional performing the diagnostic or therapeutic service that the sedation supports; age 5 years or older, first 30 minutes intra-service time

●99156●99157

D +99150

Moderate sedation services (other than those services described by codes 00100-01999), provided by a physician or other qualified health care professional other than the health care professional performing the diagnostic or therapeutic service that the sedation supports; each additional 15 minutes intra-service time

●99157

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Action

CPT Description

● 99151

Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, …: initial 15 minutes of intraservice time, patient younger than 5 years of age

● 99152

Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, …; initial 15 minutes of intraservice time, patient age 5 years or older

● +99153

Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status; each additional 15 minutes intraservice time

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12/9/2016 256


● 99155

Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; ; initial 15 minutes of intraservice time, patient younger than 5 years of age

● 99156

Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; initial 15 minutes of intraservice time, patient age 5 years or older

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12/9/2016 257


● +99157

Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; each additional 15 minutes intraservice time

D 99420Administration and interpretation of health risk assessment instrument (eg, health hazard appraisal)

●96160●96161

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CY 2017 CPT Changes – Category II Codes

12/9/2016 258


▲ 4151FPatient did not start or is not receiving antiviral treatment for Hepatitis C during the measurement period (HEP-C)[PCPI]

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12/9/2016 259


D 0019TExtracorporeal shock wave involving musculoskeletal system, not otherwise specified, low energy

D 0169TStereotactic placement of infusion catheter(s) in the brain for delivery of therapeutic agent(s), including computerized stereotactic planning and burr hole(s)

D 0171TInsertion of posterior spinous process distraction device (including necessary removal of bone or ligament for insertion and imaging guidance), lumbar; single level

●22867●22869

D +0172T

Insertion of posterior spinous process distraction device (including necessary removal of bone or ligament for insertion and imaging guidance), lumbar; each additional level

●22868●22870

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CY 2017 CPT Changes - Category II Codes

12/9/2016 260


▲ 0274T

Percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy), any method, under indirect image guidance (eg, fluoroscopic, CT), with or without the use of an endoscope, single or multiple levels, unilateral or bilateral; cervical or thoracic

▲ 0275T

Percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy), any method, under indirect image guidance (eg, fluoroscopic, CT), with or without the use of an endoscope, single or multiple levels, unilateral or bilateral; lumbar

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12/9/2016 261


D 0281T

Percutaneous transcatheter closure of the left atrial appendage with implant, including fluoroscopy, transseptal puncture, catheter placement(s), left atrial angiography, left atrial appendage angiography, radiological supervision and interpretation

●33340

D 0282T

Percutaneous or open implantation of neurostimulator electrode array(s), subcutaneous (peripheral subcutaneous field stimulation), including imaging guidance, when performed, cervical, thoracic or lumbar; for trial, including removal at the conclusion of trial period

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12/9/2016 262


D 0284TRevision or removal of pulse generator or electrodes, including imaging guidance, when performed, including addition of new electrodes, when performed

D 0285TElectronic analysis of implanted peripheral subcutaneous field stimulation pulse generator, with reprogramming when performed

D 0286TNear-infrared spectroscopy studies of lower extremity wounds (eg, for oxyhemoglobin measurement)

D 0287TNear-infrared guidance for vascular access requiring real-time digital visualization of subcutaneous vasculature for evaluation of potential access sites and vessel patency

D 0288TAnoscopy, with delivery of thermal energy to the muscle of the anal canal (eg, for fecal incontinence)

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12/9/2016 263


D +0289TCorneal incisions in the donor cornea created using a laser, in preparation for penetrating or lamellar keratoplasty

D +0291T

Intravascular optical coherence tomography (coronary native vessel or graft) during diagnostic evaluation and/or therapeutic intervention, including imaging supervision, interpretation, and report; initial vessel

▲92978

D +0292T

Intravascular optical coherence tomography (coronary native vessel or graft) during diagnostic evaluation and/or therapeutic intervention, including imaging supervision, interpretation, and report; each additional vessel

▲92979

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12/9/2016 264


D 0336TLaparoscopy, surgical, ablation of uterine fibroid(s), including intraoperative ultrasound guidance and monitoring, radiofrequency

●58674

D 0392TLaparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device (ie, magnetic band)

●43284

D 0393T Removal of esophageal sphincter augmentation device ●43285

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12/9/2016 265


● 0408T

Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; pulse generator with transvenous electrodes

● 0409TInsertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; pulse generator only

● 0410TInsertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; atrial electrode only

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12/9/2016 266


● 0411TInsertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; ventricular electrode only

● 0412TRemoval of permanent cardiac contractility modulation system; pulse generator only

● 0413TRemoval of permanent cardiac contractility modulation system; transvenous electrode (atrial or ventricular)

● 0414TRemoval and replacement of permanent cardiac contractility modulation system pulse generator only

● 0415TRepositioning of previously implanted cardiac contractility modulation transvenous electrode (atrial or ventricular lead)

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12/9/2016 267


● 0416TRelocation of skin pocket for implanted cardiac contractility modulation pulse generator

● 0417T

Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, including review and report, implantable cardiac contractility modulation system

● 0418TInterrogation device evaluation (in person) with analysis, review and report, includes connection, recording and disconnection per patient encounter, implantable cardiac contractility modulation system

● 0419TDestruction of neurofibroma, extensive (cutaneous, dermal extending into subcutaneous); face, head and neck, greater than 50 neurofibromas

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12/9/2016 268


● 0420TDestruction of neurofibroma, extensive (cutaneous, dermal extending into subcutaneous); trunk and extremities, extensive, greater than 100 neurofibromas

● 0421T

Transurethral waterjet ablation of prostate, including control of post-operative bleeding, including ultrasound guidance, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included when performed)

● 0422TTactile breast imaging by computer-aided tactile sensors, unilateral or bilateral

● 0423T Secretory type II phospholipase A2 (sPLA2-IIA)

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12/9/2016 269


● 0424TInsertion or replacement of neurostimulator system for treatment of central sleep apnea; complete system (transvenous placement of right or left stimulation lead, sensing lead, implantable pulse generator)

● 0425TInsertion or replacement of neurostimulator system for treatment of central sleep apnea; sensing lead only

● 0426TInsertion or replacement of neurostimulator system for treatment of central sleep apnea; stimulation lead only

● 0427TInsertion or replacement of neurostimulator system for treatment of central sleep apnea; pulse generator only

● 0428TRemoval of neurostimulator system for treatment of central sleep apnea; pulse generator only

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12/9/2016 270


● 0429TRemoval of neurostimulator system for treatment of central sleep apnea; sensing lead only

● 0430TRemoval of neurostimulator system for treatment of central sleep apnea; stimulation lead only

● 0431TRemoval and replacement of neurostimulator system for treatment of central sleep apnea, pulse generator only

● 0432TRepositioning of neurostimulator system for treatment of central sleep apnea; stimulation lead only

● 0433TRepositioning of neurostimulator system for treatment of central sleep apnea; sensing lead only

● 0434TInterrogation device evaluation implanted neurostimulator pulse generator system for central sleep apnea

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12/9/2016 271


● 0435TProgramming device evaluation of implanted neurostimulator pulse generator system for central sleep apnea; single session

● 0436TProgramming device evaluation of implanted neurostimulator pulse generator system for central sleep apnea; during sleep study

● +0437TImplantation of non-biologic or synthetic implant (eg, polypropylene) for fascial reinforcement of the abdominal wall

● 0438TTransperineal placement of biodegradable material, periprostatic (via needle), single or multiple, includes image guidance

● +0439TMyocardial contrast perfusion echocardiography, at rest or with stress, for assessment of myocardial ischemia or viability

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CY 2017 CPT Changes

12/9/2016 272


● 0440TAblation, percutaneous, cryoablation, includes imaging guidance; upper extremity distal/peripheral nerve

● 0441TAblation, percutaneous, cryoablation, includes imaging guidance; lower extremity distal/peripheral nerve

● 0442TAblation, percutaneous, cryoablation, includes imaging guidance; nerve plexus or other truncal nerve (eg, brachial plexus, pudendal nerve)

● 0443TReal-time spectral analysis of prostate tissue by fluorescence spectroscopy, including imaging guidance

● 0444TInitial placement of a drug-eluting ocular insert under one or more eyelids, including fitting, training, and insertion, unilateral or bilateral

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12/9/2016 273


● 0445TSubsequent placement of a drug-eluting ocular insert under one or more eyelids, including re-training, and removal of existing insert, unilateral or bilateral

● 0446TCreation of subcutaneous pocket with insertion of implantable interstitial glucose sensor, including system activation and patient training

● 0447TRemoval of implantable interstitial glucose sensor from subcutaneous pocket via incision

● 0448TRemoval of implantable interstitial glucose sensor with creation of subcutaneous pocket at different anatomic site and insertion of new implantable sensor, including system activation

● 0449TInsertion of aqueous drainage device, without extraocular reservoir, internal approach, into the subconjunctival space; initial device

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12/9/2016 274


● +0450TInsertion of aqueous drainage device, without extraocular reservoir, internal approach, into the subconjunctival space; each additional device

● 0451T

Insertion or replacement of a permanently implantable aortic counterpulsation ventricular assist system, endovascular approach, and programming of sensing and therapeutic parameters; complete system (counterpulsation device, vascular graft, implantable vascular hemostatic seal, mechano-electrical skin .interface and subcutaneous electrodes)

● 0452T

Insertion or replacement of a permanently implantable aortic counterpulsation ventricular assist system, endovascular approach, and programming of sensing and therapeutic parameters; aortic counterpulsation device and vascular hemostatic seal

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● 0453TInsertion or replacement of a permanently implantable aortic counterpulsation ventricular assist system, endovascular approach, and programming of sensing and therapeutic parameters; mechano-electrical skin interface

● 0454TInsertion or replacement of a permanently implantable aortic counterpulsation ventricular assist system, endovascular approach, and programming of sensing and therapeutic parameters; subcutaneous electrode

● 0455TRemoval of permanently implantable aortic counterpulsation ventricular assist system; complete system (aortic counterpulsation device, vascular hemostatic seal, mechano-electrical skin interface and electrodes)

● 0456TRemoval of permanently implantable aortic counterpulsation ventricular assist system; aortic counterpulsation device and vascular

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● 0457TRemoval of permanently implantable aortic counterpulsation ventricular assist system; mechano-electrical skin interface

● 0458TRemoval of permanently implantable aortic counterpulsation ventricular assist system; subcutaneous electrode

● 0459TRelocation of skin pocket with replacement of implanted aortic counterpulsation ventricular assist device, mechano-electrical skin interface and electrodes

● 0460TRepositioning of previously implanted aortic counterpulsation ventricular assist device; subcutaneous electrode

● 0461TRepositioning of previously implanted aortic counterpulsation ventricular assist device; aortic counterpulsation device

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● 0462T

Programming device evaluation (in person) with iterative adjustment of the implantable mechano-electrical skin interface and/or external driver to test the function of the device and select optimal permanent programmed values with analysis, including review and report, implantable aortic counterpulsation ventricular assist system, per day

● 0463T

Interrogation device evaluation (in person) with analysis, review and report, includes connection, recording and disconnection per patient encounter, implantable aortic counterpulsation ventricular assist system, per day

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Source Authorities

• CY 2017 MPFS Final Rule:https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1654-F.html

• CY 2017 OPPS Final Rule:https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices-Items/CMS-1656-FC.html

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https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1654-F.html

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices-Items/CMS-1656-FC.html

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Source Authorities

• FY 2017 IPPS Final Rule (contains Observation Act)https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2017-IPPS-Final-Rule-Home-Page.html

• Observation “MOON” Notice:https://www.cms.gov/Regulations-and-Guidance/Legislation/PaperworkReductionActof1995/PRA-Listing-Items/CMS-10611.html

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https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2017-IPPS-Final-Rule-Home-Page.html

https://www.cms.gov/Regulations-and-Guidance/Legislation/PaperworkReductionActof1995/PRA-Listing-Items/CMS-10611.html

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Thank-You!

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