2009 CPT® Changes

Effective January 1, 2009
Below please find the 2009 CPT changes and/or revisions as outlined in the American Medical Association CPT 2009 Edition. If you have any questions regarding the information below, please contact Jennifer Carlin Young at (904) 353-7878 ext. 123, jyoung@aace.com. Modifiers
This list includes all of the modifiers applicable to CPT® 2009 codes. ►(Modifier 21 has been deleted. To report prolonged physician services, see 99354-99357)◄ Rationale Modifier 21 for reporting a prolonged evaluation and management service has been deleted. This modifier provided a duplicate mechanism for the same concept that is reported with prolonged Evaluation and Management Services codes 99354-99359, violating the CPT® concept of unique methods of concept reporting.

EVALUATION AND MANAGEMENT
Prolonged Physician Service With Direct (Face-to-Face) Patient Contact
►Codes 99354-99357 are used when a physician provides prolonged service involving direct (face-to-face) patient contact that is beyond the usual service in either the inpatient or outpatient setting. This service is reported in addition to the designated evaluation and management services at any level and any other physician services provided at the same session as evaluation and management services. Appropriate codes should be selected for supplies provided or procedures performed in the care of the patient during this period. Codes 99354-99355 are used to report the total duration of face-to-face time spent by a physician on a given date providing prolonged service, even if the time spent by the physician on that date is not continuous. Codes 9935699357 are used to report the total duration of unit time spent by a physician on a given date providing prolonged services to a patient, even if the time spent by the physician on that date is not continuous.◄ Code 99354 or 99356 is used to report the first hour of prolonged service on a given date, depending on the place of service. ►Either code should be used only once per date, even if the time spent by the physician is not continuous on that date. Prolonged service of less than 30 minutes total duration on a given date is not separately reported because the work involved is included in the total work of the evaluation and management codes.◄ Code 99355 or 99357 is used… ►The use of the time based add-on codes requires that the primary evaluation and management service have a typical or specified time published in the CPT® codebook.◄

CPT® 2009 Changes: An Insider’s View ©2008 American Medical Association All rights reserved. 1

The following examples illustrate the correct… Total Duration of Prolonged Services Less than 30 minutes (less than 1/2 hour) 30-74 minutes (1/2 hr. – 1 hr. 14 min.) 75-104 (1 hr. 15 min. – 1 hr. 44 min.) ►105 or more (1 hr. 45 min. or more) +▲99354 Codes(s) Not reported separately 99354 X 1 99354 X 1 AND 99355 X 1 99354 X 1 AND 99355 X 2 ◄

Prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual service; first hour (List separately in addition to code for office or other outpatient Evaluation and Management Service) ►(Use 99354 in conjunction with 99201-99215, 99241-99245, 99324-99337, 99341-99350, 90809, 90815)◄

+▲99355

each additional 30 minutes (List separately in addition to code for prolonged physician service) (Use 99355 in conjunction with 99354)

+▲99356

Prolonged physician service in the inpatient setting, requiring unit/floor time beyond the usual service; first hour (List separately in addition to code for inpatient Evaluation and Management service) ► (Use 99356 in conjunction with 99221-99233, 99251099255, 99304-99310, 90822, 90829) ◄

+▲99357

each additional 30 minutes (List separately in addition to code for prolonged physician service) (Use 99357 in conjunction with 99356)

Rationale The guidelines for the face-to-face outpatient and inpatient prolonged evaluation and management services, reported with codes 99354-99357, have been revised to indicate that these are intended to be reported with evaluation and management services in addition to any other physician services reported at the same session. The guidelines for the outpatient services have been revised to indicate that only the outpatient services are intended to report the total duration of the time spent (continuous or non-continuous) by the physician on the unit. Directions have also been added to instruct that if a time-based add-on code is reported, it can only be used with evaluation and management services codes with typical or specified times included in their descriptors. An abbreviated table of time examples has been revised for clarity. The referenced codes in the parenthetical instructions following codes 99354 and 99356 have been revised to reflect appropriate services (psychotherapy with medical evaluation and management) and sites of services (inpatient nursing facility services) for these categories. These services should not be reported in addition to the team conference services (99366-99368), telephone (99441-99443), or other non-face-to-face services.

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SURGERY
General
10021 10022 Fine needle aspiration; without imaging guidance with imaging guidance

►(For percutaneous needle biopsy other than fine needle aspiration, see 20206 for muscle, 32400
for pleura, 32405 for lung or mediastinum, 42400 for salivary gland, 4700, 47001 for liver, 48102 for pancreas, 49180 for abdominal or retroperitoneal mass, 60100 for thyroid, 62267 for nucleus pulposus, intervertebral disc, or paravertebral tissue, 62269 for spinal cord)◄ Rationale To support the addition of code 66267 to report percutaneous aspiration within the nucleus pulposus, intervertebral disc, or paravertebral tissue for diagnostic purposes, the cross-reference following code 10022 was revised to refer users to 62267 when reporting interdiscal percutaneous diagnostic aspiration.

Integumentary System
Skin, Subcutaneous and Accessory Structures EXICISION – DEBRIDEMENT 11000 +▲11001 Debridement of extensive eczematous or infected skin’ up to 10% of body surface each additional 10% of the body surface, or part thereof (List separately in addition to code for primary procedure)

REMOVAL OF SKIN TAGS 11200 +▲11201 Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions each additional 10 lesions, or part thereof (List separately in additional to code for primary procedure)

Rationale Codes 11001, 11201, and 11922 have been editorially revised with the addition of “or part thereof” to clarify that the existing phrase “each additional 10% of the body surface,” “each additional 10 lesions,” or “each additional 20.0 sq cm” is intended to include repair of any additional percentage within the stated measurement. These revisions were made to address confusion regarding reporting for repairs over the initial measurement, whether by percentage, number of lesions, or area measurement, and to provide consistency with other add-on integumentary codes that include measurement as a reporting mechanism.

CPT® 2009 Changes: An Insider’s View ©2008 American Medical Association All rights reserved. 3

RADIOLOGY
Bone/Joint Studies
77080 Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine)

77081 appendicular skeletons (peripheral) (eg, radius, wrist, heel) 77082 vertebral fracture assessment

►(For dual- energy X-ray absorptiometry (DEXA) body composition study, use 76499)◄
Rationale A parenthetical note has been added following code 77082 to direct users to the appropriate code to report a dualenergy absorptiometry (DEXA) body composition study.

Nuclear Medicine
Diagnostic OTHER PROCEDURES ●78808 Injection procedure for radiopharmaceutical localization by non-imaging probe study, intravenous (eg, parathyroid adenoma) ►(For sentinel lymph node identification, use 38792)◄ Rationale Nuclear medicine code 78808 was established to report an injection for radiopharmaceutical localization by non imaging probe study. This code reflects the resources required to provide those radioactive drugs by intravenous routes prior to gamma probe localization (eg, parathyroid tumors). Non-imaging gamma probe procedures in which a radiopharmaceutical is prepared, injected, and handled in accordance with acceptable regulatory and safety requirements are done during surgery as part of and during neck exploration for parathyroid tumors or for sentinel nodes in cancer patients (usually breast and melanoma). A parenthetical note has been added to clarify that code 38792 may be used for the interstitial injection preceding surgery, during which a gamma probe may be used for localization of a sentinel node.

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PATHOLOGY AND LABORATORY
Organ or Disease-Oriented Panels
▲80048 Basic metabolic panel (Calcium, total) This panel must include the following: Calcium ►, total ◄ (82310) Carbon dioxide (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Potassium (84132) Sodium (94295) Urea nitrogen (BUN) (84520) ▲80053 Comprehensive metabolic panel This panel must include the following: Albumin (82040) Bilirubin, total (82247) Calcium►, total◄ (82310) Carbon dioxide (bicarbonate) (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Phosphatase, alkaline (84075) Potassium (84132) Protein, total (84155) Sodium (84295) Transferase, alanine amino (ALT) (SGPT) (84460) Transferase, aspartate amino (AST) (SGOT) (84450) Urea nitrogen (BUN) (84520) ▲80069 Renal function panel This panel must include the following: Albumin (82040) Calcium ►, total◄ (82310)
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Carbon dioxide (bicarbonate) (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Phosphorus inorganic (phosphate) 84100) Potassium (84132) Sodium (84295) Urea nitrogen (BUN) (84520)

Evocative/Suppression Testing
►The following test panels involve the administration of evocative or suppressive agents, and the baseline and subsequent measurement of their effects on chemical constituents. These codes are to be used for the reporting of the laboratory component of the overall testing protocol. For the physician’s administration of the evocative or suppressive agents, see 96360, 96361, 96372-96374, 96375; for the supplies and drugs, see 99070. To report physician attendance and monitoring during the testing, use the appropriate evaluation and management code, including the prolonged physician care codes if required. Prolonged physician care codes are not separately reported when evocative/suppression testing involves prolonged infusions reported with 96360, 96361. In the code descriptors where reference is made to a particular analyte (eg, Cortisol: 82533 x 2) the “x 2” refers to the number of times the test for that particular analyte is performed.◄ 84000 ACTH stimulation panel; for adrenal insufficiency. This panel must include the following: Cortisol (82533 x 2)

Rationale In support of the deletion and renumbering of codes 90760-90799, the Evocative/Suppression Testing guidelines have been revised to reflect the appropriate codes to report for infusion services.

Chemistry
82955 82960 Glucose-6-phosphate dehydrogenase (G6PDP); quantitative screen ►(For glucose tolerance test with medication, use 96374 in addition)◄ Rationale In support of the deletion and renumbering of codes 90760-90799, the cross-reference following code 82960 has been revised to reflect the appropriate codes to report for infusion services.

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MEDICINE
Vaccines, Toxoids
►(90760 has been deleted. To report, use 96360) ◄ ►(90761 has been deleted. To report, use 96361) ◄ ►(90765 has been deleted. To report, use 96365) ◄ ►(90766 has been deleted. To report, use 96366) ◄ ►(90767 has been deleted. To report, use 96367) ◄ ►(90768 has been deleted. To report, use 96368) ◄ ►(90769 has been deleted. To report, use 96369) ◄ ►(90770 has been deleted. To report, use 96370) ◄ ►(90771 has been deleted. To report, use 96371) ◄ ►(90772 has been deleted. To report, use 96372) ◄ ►(90773 has been deleted. To report, use 96373) ◄ ►(90774 has been deleted. To report, use 96374) ◄ ►(90775 has been deleted. To report, use 96375) ◄ ►(90776 has been deleted. To report, use 96376) ◄ ►(90779 has been deleted. To report, use 96379) ◄ Rationale In order to assist users in comparison and use of the infusion services procedures, codes 90760-90779 have been deleted and renumbered for proximity to the chemotherapy and other complex infusion services reported with codes 96401-96549. In addition to deletion and renumbering of these services, movement of the codes allowed condensation of the guidelines with revision to reflect overarching principles between each of the code series.

Endocrinology
▲95250 Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; sensor placement, hook-up, calibration of monitor, patient training, removal of sensor, and printout of recording ►(Do not report 95250 more than once per month)◄ (Do not report 95250 in conjunction with 99091) ▲95251 interpretation and report ►(Do not report 95251 more than once per month)◄ ►(Do not report 95251 in conjunction with 99091)◄
CPT® 2009 Changes: An Insider’s View ©2008 American Medical Association All rights reserved. 7

Rationale Codes 95250 and 95251 have been revised to reflect ambulatory continuous glucose monitoring of interstitial tissue fluid for a minimum of up to 72 hours. Prior to 2009, code 95250 specified monitoring of up to 72 hours. This change is more reflective of current practice. Code 95251 has been revised by removing the specification of interpretation and report performed by a physician, because the interpretation and report may be performed by a health care professional other than a physician. Codes 95250 and 95251 may not be reported more than once per month, and instructional notes have been added following each code to indicate this code may not be reported in conjunction with the collection and interpretation of physiologic data code 99091.

Health and Behavior Assessment/Intervention
►Hydration, Therapeutic, Prophylactic, Diagnostic Injections and Infusions, and Chemotherapy and Other Highly Complex Drug or Highly Complex Biologic Agent Administration◄ ►Physician work related to hydration, injection, and infusion services predominantly involves affirmation of treatment plan and direct supervision of staff.◄ ►If a significant, separately identifiable Evaluation and Management service is performed, the appropriate E/M service code should be reported using modifier 25 in addition to 96360-96549. For same day E/M service, a different diagnosis is not required. If performed to facilitate the infusion or injection, the following services are included and are not reported separately: a. b. c. d. Use of local anesthesia IV start Access to indwelling IV, subcutaneous catheter or port Flush at conclusion of infusion e. Standard tubing, syringes, and supplies◄ ►(For declotting a catheter or port, use 36593) ►When multiple drugs are administered, report the service(s) and the specific materials or drugs for each. When administering multiple infusions, injections or combinations, only one “initial” service code should be reported, unless protocol requires that two separate IV sites must be used. If an injection or infusions is of a subsequent or concurrent nature, even if it is the first such service within that group of services, then a subsequent of concurrent code from the appropriate section should be reported (eg, the first IV push given subsequent to an initial one-hour infusion is reported using a subsequent IV push code). When these codes are reported by the physician, the “initial” code that best describes the key or primary reason for the encounter should always be reported irrespective of the order in which the infusions or injections occur. When these codes are reported by the facility, the following instructions apply. The initial code should be selected using a hierarchy whereby chemotherapy services are primary to therapeutic, prophylactic, and diagnostic services which are primary to hydration services. Infusions are primary to pushes, which are primary to injections. When reporting codes for which infusion time is a factor, use the actual time over which the infusion is administered. Intravenous or intra-arterial push is defined as: (a) an injection in which the health care professional who administers the substance/drug is continuously present to administer the injection and observe the patient, or (b) an infusion of 15 minutes or less.◄
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►Hydration◄ ►Codes 96360-96361 are intended to report a hydration IV infusion to consist of a pre-packaged fluid and electrolytes (eg, normal saline, DF-1/2 normal saline+30mEq KC1/liter), but are not used to report infusion of drugs or other substances. Hydration IV infusions typically require direct physician supervision for purposes of consent, safety oversight, or intraservice supervision of staff. Typically such infusions require little special handling to prepare or dispose of, and staff that administer these do not typically require advanced practice training. After initial set-up, infusion typically entails little patient risk and thus little monitoring. These codes are not intended to be reported by the physician in the facility setting.◄ ● 96360 Intravenous infusion, hydration; initial, 31 minutes to 1 hour. ►(Do not report 96360 if performed as a concurrent infusion service)◄ ►(Do not report intravenous infusion for hydration of 30 minutes or less)◄ +● 96361 each additional hour (List separately in addition to code for primary procedure) ►(Use 96361 in conjunction with 96360)◄ ►(Do not report 96361 for hydration infusion intervals of greater than 30 minutes beyond 1 hour increments)◄ ►(Report 96361 to identify hydration if provided as a secondary or subsequent service after a different initial service [96360, 96365, 96374, 96409, 96413] is administered through the same IV access)◄ ►Therapeutic, Prophylactic, and Diagnostic Injections and Infusions (Excludes Chemotherapy and Other Highly Complex Drug or Highly Complex Biologic Agent Administration◄ ►A therapeutic, prophylactic, or diagnostic IV infusion or injection (other than hydration) is for the administration of substances/drugs. When fluids are used to administer the drug(s), the administration of the fluid is considered incidental hydration and is not separately reportable. These services typically require direct physician supervision for any or all purposes of patient assessment, provision of consent, safety oversight, and intra-service supervision of staff. Typically, such infusions require special consideration to prepare, dose or dispose of, require practice training and competency for staff who administer the infusions, and require periodic patient assessment with vital sign monitoring during the infusion. These codes are not intended to be reported by the physician in the facility setting. See codes 96401-96549 for the administration of chemotherapy or other highly complex drug or highly complex biologic agent services. These highly complex services require advanced practice training and competency for staff who provide these services; special considerations for preparation, dosage or disposal; and commonly, these services entail significant patient risk and frequent monitoring. Examples are frequent changes in the infusion rate, prolonged presence of nurse administering the solution for patient monitoring and infusion adjustments, and frequent conferring with the physician about these issues.◄ ►(Do not report 96365-96379 with codes for which IV push or infusion is an inherent part of the procedure [eg, administration of contrast material for a diagnostic imaging study])◄ ● 96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour

CPT® 2009 Changes: An Insider’s View ©2008 American Medical Association All rights reserved. 9

+● 96366

each additional hour (List separately in addition to code for primary procedure) ►(Report 96366 in conjunction with 96365, 96367)◄ ►(Report 96366 for additional hour[s] of sequential infusion)◄ ►(Report 96366 for infusion intervals of greater than 30 minutes beyond 1 hour increments)◄

+● 96367

additional sequential infusion, up to 1 hour (List separately in addition to code for primary procedure) ►(Report 96367 in conjunction with 96365, 96374, 96409, 96413 if provided as a secondary or subsequent service after a different initial service is administered through the same IV access. Report 96367 only once per sequential infusion of same infusate mix)◄

+● 96368

concurrent infusion (List separately in addition to code for primary procedure) ►(Report 96368 only once per encounter)◄ ►(Report 96368 in conjunction with 96365, 96366, 96413, 96415, 96416)◄

● 96369

Subcutaneous infusion for therapy or prophylaxis (specify substance or drub); initial, up to 1 hour, including pump set-up and establishment of subcutaneous infusion site(s) ►(For infusions of 15 minutes or less, use 96372)◄ each additional hour (List separately in addition to code for primary procedure) ►(Use 96370 in conjunction with 96369)◄ ►(Use 96370 for infusion intervals of greater than 30 minutes beyond 1 hour increments)◄

+● 96370

+● 96371

additional pump set-up with establishment of new subcutaneous infusion site(s). List separately in addition to code for primary procedure) ►(Use 96371 in conjunction with 96369)◄ ►(Use 96369, 96371 only once per encounter)◄

+● 96372

Therapeutic, prophylactic, or diagnostic injection (specify substance or drub); subcutaneous or intramuscular ►(For administration of vaccines/toxoids, see 90465, 90466, 90471, 90472)◄ ►(Report 96372 for non-antineoplastic nonhormonal injection therapy)◄ ►(Report 96401 for anti-neoplastic nonhormonal injection therapy)◄ ►(Report 96402 for anti-neoplastic hormonal injection therapy)◄

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►(Physicians do not report 96372 for injections given without direct physician supervision. To report, use 99211. Hospitals may report 96372 when the physician is not present)◄ ►(96372 does not include injections for allergen immunotherapy. For allergen immunotherapy injections, see 95115-95117)◄ ● 96373 ● 96374 +● 96375 intra-arterial intravenous push, single or initial substance/drug each additional sequential intravenous push of a new substance/drug (List separately in addition to code for primary procedure) ►(Use 96375 in conjunction with 96365, 96374, 96409, 96413)◄ ►(Report 96375 to identify intravenous push of a new substance/drug if provided as a secondary or subsequent service after a different initial service is administer through the same IV access)◄ +● 96376 each additional sequential intravenous push of the same substance/drug provided in the facility (List separately in addition to code for primary procedure) ►(Do not report 96376 for a push performed within 30 minutes of a reported push of the same substance or drug)◄ ►(96376 may be reported by facilities only)◄ +● 96379 Unlisted therapeutic, prophylactic, or diagnostic intravenous or intra-arterial injection or infusion ►(For allergy immunology, see 95004 et seq)◄

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