Coding changes that will impact radiology in 2021

By Erin Stephens, AuntMinnie.com contributing writer

January 8, 2021 -- The big news in revisions to current procedural terminology (CPT) codes for 2021 is the overhaul of the evaluation and management (E&M) section, reducing documentation requirements and introducing new rules for determining the level of coding. These changes will affect interventional radiologists and radiation oncologists more than they will impact the day-to-day work of diagnostic radiologists.

Erin Stephens of Healthcare Administrative Partners
Erin Stephens of Healthcare Administrative Partners.

First, we will review the other non-E&M code changes affecting diagnostic and interventional radiology for 2021.

Diagnostic radiology

Chest CT and lung cancer screening

The code for low-dose lung cancer screening (G0297) has been replaced by the new code 71271. The code G0296, "Counseling visit to discuss need for lung cancer screening," remains in use for 2021.

The professional component of the new code 71271 has been assigned a 4.8% higher relative value unit (RVU) value than G0297 had, while the global RVU has been slashed 36%; however, due to the revaluation of the conversion factor the pricing for the professional component (PC) increased only slightly while the global value decreased 38% as shown here:

  2021 (71271) 2020 (G0297)
    RVU value Fee Schedule* RVU value Fee Schedule
Professional component Work RVU 1.08   1.02  
Total RVU (+4.8%) 1.52 (+1.4%) $53.04 1.45 $52.33
Global Work RVU 1.08   1.02  
Total RVU (-36%) 4.32 (-38%) $150.74 6.70 $241.80
* Using the values finalized by the Consolidated Appropriations Act.

The codes that describe CT Thorax (71250-71270) are now to be used only for diagnostic exams, not screening exams.

Breast CT

New codes have been created for breast CT exams, as described in the table below.

CT Breast, including 3D rendering when performed: Unilateral Bilateral
Without contrast 0633T 0636T
With contrast 0634T 0637T
Without contrast followed by with contrast 0635T 0638T

Miscellaneous

  • CPT code 74425 "Urography, antegrade, radiological supervision and interpretation" may now be used with any antegrade exam. Previously it was specifically for a pyelostogram, nephrostogram or loopogram only.
  • CPT code 76970, "Ultrasound study follow-up," has been deleted.
  • CPT code 78135, "Red cell survival study; differential organ/tissue kinetics (e.g., splenic and/or hepatic sequestration)," has been deleted.

Interventional radiology

Lung biopsy

The code 32405, "Biopsy, lung or mediastinum, percutaneous needle," has been replaced by a new code 32408, "Core needle biopsy, lung or mediastinum, percutaneous, including imaging guidance, when performed." Accordingly, imaging guidance may no longer be billed separately. When more than one core needle biopsy of the lung or mediastinum is performed on separate lesions during the same session on the same day, then 32408 is billed once for each additional lesion along with modifier -59.

Cardiac catheterization

A new series of codes was created to report the creation of effective intracardiac blood flow in the setting of congenital heart defects. Our coders recommend that the CPT book should be consulted to be sure the extensive guidelines related to these procedures are followed. The new codes are described in the following table.

CPT Code Description
33741 Transcatheter atrial septostomy (TAS) for congenital cardiac anomalies to establish effective intracardiac flow, including all imaging guidance by the proceduralist, when performed, any method (e.g., Rashkind, Sang-Park, balloon, cutting balloon, blade)
33745 Transcatheter intracardiac shunt (TIS) creation by stent placement for congenital cardiac anomalies to establish effective intracardiac flow, including the following

  • All imaging guidance by the proceduralist, when performed
  • Left and right heart diagnostic cardiac catheterization for congenital cardiac anomalies, and
  • Target zone angioplasty, when performed (e.g., atrial septum, Fontan fenestration, right ventricular outflow tract, Mustard/Senning/Warden baffles)

Initial cardiac shunt

33746 Add-on Each additional intracardiac shunt location

Note that multiple stents placed in a single location may only be reported with a single code (33745). Add-on code 33746 is to be used when additional stents in different intracardiac locations are placed in the same session.

Ventricular assist device (VAD) insertion

The coding of these procedures was revised to differentiate between left- and right-heart procedures, encompassing either initial placement or replacement of a percutaneous VAD.

CPT Code Description
  Insertion of ventricular assist device (VAD), percutaneous including radiological supervision and interpretation;
33995 Right heart, venous access only
33990 Left heart, arterial access only
33991 Left heart, both arterial and venous access, with transseptal puncture
  Removal of percutaneous ventricular assist device (VAD), at separate and distinct session from insertion
33992 Left heart, arterial or arterial and venous cannula(s)
33997 Right heart, venous cannula
33993 Repositioning of percutaneous right or left heart ventricular assist device (VAD) with imaging guidance at separate and distinct session from insertion.

Endovascular venous arterialization

Coding has been available for endovascular revascularization (37228-37231 and 0505T), but not for arterialization. A new code (0620T) has been created as follows:

"Endovascular venous arterialization, tibial or peroneal vein, with transcatheter placement of intravascular stent graft(s) and closure by any method, including

    • Percutaneous or open vascular access,
    • Ultrasound guidance for vascular access when performed,
    • All catheterization(s) and intraprocedural roadmapping and imaging guidance necessary to complete the intervention, and
    • All associated radiological supervision and interpretation, when performed."

    Ultrasound ablation of pulmonary arteries

    A new code (0632T) has been created as follows:

    "Percutaneous transcatheter ultrasound ablation of nerves innervating the pulmonary arteries, including:

    • Right heart catheterization
    • Pulmonary artery angiography, and
    • All imaging guidance."

    Evaluation & management services

    Under the revised E&M coding structure, physicians may elect to document a visit based either on time spent or on medical decision-making. Level 1 (99201) for new patients has been eliminated, leaving four levels of billing for new patients and five levels for established patients.

    Until now, the level of coding has been determined by time spent face-to-face with the patient and by evaluating the three components of an exam:

    • The patient's history,
    • The physical examination, and
    • The level of medical decision-making

    The new system that begins in 2021 will be based only on the following:

    • The level of medical decision-making or
    • The total time involved in the service of the patient, including non-face-to-face activities performed by the physician.

    The following table summarizes the criteria for a new patient.

    For a new patient with medically appropriate history and/or physical exam
    CPT Code Medical decision-making is: Time spent is:
    99202 Straightforward 15-29 minutes
    99203 Low 30-44 minutes
    99204 Moderate 45-59 minutes
    99205 High 60-74 minutes

    For an established patient, a level 1 visit (CPT 99211) might not require a physician to be involved. This could be a nurse visit or blood pressure check. There is minimal medical decision-making and no prescribed time element. The remaining billing levels for an established patient are summarized as illustrated in the following table.

    For an established patient with medically appropriate history and/or physical exam
    CPT Code Medical decision-making is: Time spent is:
    99212 Straightforward 10-19 minutes
    99213 Low 20-29 minutes
    99214 Moderate 30-39 minutes
    99215 High 40-54 minutes

    Medicare has approved a new code, G2212, to be used for encounters that exceed the maximum time for a level 5 (99205/99215) visit. Its description is "Prolonged office or other outpatient evaluation and management services (beyond the total time of the primary procedure which has been selected using total time), requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service; each 15 minutes." This mirrors the language of CPT code 99417 that might be approved by payors other than Medicare.

    Conclusion

    The coding changes described here will have minimal impact on the daily work of diagnostic radiologists, while interventionalists and radiation oncologists will have to become familiar with the revised E&M coding and documentation structure. Other than the global fee cut to the CT Lung Screening code, these changes will have little financial impact directly.

    However, the restructuring of the E&M section has far-reaching reimbursement implications across the spectrum of the Medicare Physician Fee Schedule.

    Erin Stephens is senior client manager, education at Healthcare Administrative Partners.

    The comments and observations expressed are those of the author and do not necessarily reflect the opinions of AuntMinnie.com.


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