This article provides a high-level overview of code changes for 2012. It is not meant to be an all-inclusive introduction to either the code changes or the guideline changes being introduced in 2012.
The new CPT codes are indicated in the CPT book with a ; revised codes have a and guideline changes are found between sidelying triangles . A list of all additions, deletions, and revisions is found in the CPT codebook Appendix B.
The Patient Protection and Affordable Care Act (PPACA) requires all health care insurance plans to begin covering preventive services and immunizations without any cost-sharing; they must provide first-dollar-coverage for certain, specified preventive services.
Modifier 33 became effective during 2011 and has been added to the 2012 CPT Manual. This modifier should be used to identify preventive services that were provided and are covered under applicable laws and to indicate that patient cost-sharing does not apply. Do not apply co-pays or deductibles for services covered under this law.
One of these preventive services is osteoporosis screening in women. The U.S. Preventive Services Task Force (USPSTF) recommends that women aged 65 or older be screened routinely for osteoporosis. For women at increased risk for osteoporotic fractures, the USPSTF recommends that routine screening begin at age 60. Modifier 33 should be appended to the appropriate screening tests, eg, bone density tests.
E & M Update
The definitions for “new” and “established” patients in the Evaluation and Management (E & M) Guidelines have been revised to include the terms “specialties” and “subspecialties,” but “specialties” and “subspecialties” have not been defined. The CPT Manual also includes a Decision Tree to assist in determining whether a patient is “new” or “established.”
Medicare, however, identifies the following musculoskeletal specialties: Hand (specialty code 40), Orthopaedics (specialty code 20); and Sports Medicine (specialty code 23). The sports medicine specialty code was requested by the American Association of Family Physicians. Understanding the definitions and specialty recognitions is important to ensure accurate reporting of new and established patient visits in a practice that employs physicians from multiple specialties.
A guideline change removed the instruction to add Modifier 59 (distinct procedures) to the add-on code for the “each additional 20 sq cm codes” (eg 11045) in the débridement section.
Skin Replacement Surgery
Comprehensive changes were made to the Skin Replacement Surgery subsection (15271–15278). The changes include deletion of 24 codes, revision of 6 codes, and the creation of 8 new codes. This article provides an introduction to the guidelines and new codes.
The heading “Skin Substitutes” was replaced by “Skin Replacement Surgery.” The CPT codes in this section are always intended for use as “skin” replacement codes.
Subheads within the Skin Replacement Surgery subsection include “Surgical Preparation,” “Autograft/Tissue-cultured Autograft,” and “Skin Substitutes.”
CPT codes 15150–15176 and 15300–15431 were deleted and eight new codes were created. The codes for tissue-cultured autografts (15150–15157) and the new skin replacement codes (15271–15278) are defined by the anatomic location and the surface area size in square centimeters (the first 25 sq cm or the first 100 sq cm). An associated add-on code was also created (Table 1).
The new codes apply to non-autologous human skin (dermal or epidermal; cellular or acellular), grafts (eg, homograft or allograft), nonhuman skin substitute grafts (ie, xenografts), and biologics that form a sheet scaffolding for skin grafts. The graft is anchored using the surgeon’s fixation of choice; however, CPT codes 15271–15278 do not apply to products that are nongraft wound dressings, such as gels, ointments, foams, or liquids.
A new biological implant code has also been introduced: 15777—“Implantation of biologic implant (eg, acellular dermal matrix) for soft tissue reinforcement (eg, breast, trunk) (List separately in addition to code for primary procedure).” This code should be used to report biologics that are not skin replacements but are used for soft tissue reinforcement. It should be reported in addition to the primary procedure code. Modifier 51 should not be applied, and 100 percent reimbursement should be expected.
The most significant guideline change related to wound repairs is the instruction to report modifier 59 when performing multiple wound repairs of different classifications (ie, simple, intermediate, complex). Because CPT codes are defined by anatomic location and type of classification, single repairs of different anatomic classifications were reported with a modifier 51 to differentiate them as multiple procedures until this year (2012).
Two new CPT codes on the treatment of Dupuytren’s contracture were introduced. CPT code 20527—“Injection, enzyme (eg, collagenase), palmar fascial cord (ie, Dupuytren’s contracture)”—describes the work associated with the injection on the first day. CPT code 26341—“Manipulation, palmar fascial cord (ie, Dupuytren’s cord), postenzyme injection (eg, collagenase)”—describes the work on the second day for the manipulation of the cord.
Both procedures are single-use codes; CPT code 20527 carries no global period while CPT code 26341 invokes a 10-day global period. Application of a custom-fabricated splint is separately reportable on the second day.
Major changes occurred in the arthroscopy section of the 2012 CPT Manual, reflecting Medicare’s 75 percent threshold of services being reported together.
With regard to shoulder arthroscopy, CPT code 29826—“arthroscopic subacromial decompression”—is now an add-on code to CPT codes 29806–29825, 29827, and 29828. Modifier 51 should not be used and 100 percent reimbursement should be expected.
CPT code 29826 should not be reported with any procedure other than those identified as appropriate parent codes. It is not an add-on code to CPT code 23410 or 23412, and an unlisted code may not be reported to reflect this work. Instead, append modifier 22 or report 29822 or 29823 (limited or extensive débridement) as appropriate.
Changes were also made to knee arthroscopy procedures (See “2012 MPFS presents problems for orthopaedics,” AAOS Now, December 2011). CPT codes 29880 (medial and lateral meniscectomy) and 29881 (medial or lateral meniscectomy) were revised to include the work associated with the chondroplasty. These procedures were also revalued to reflect the change in physician work time required.
As the result of these changes, a chondroplasty can never be reportable on the same day as a meniscectomy (medial or lateral, or medial and lateral) on the same knee.
Mary LeGrand, RN, MA, CCS-P, CPC, is a senior consultant with KarenZupko & Associates, Inc. The article has been reviewed and approved by members of the AAOS Coding, Coverage, and Reimbursement Committee.