The recently issued Medicare Physician Fee Schedule (MPFS) Final Rule for 2018 tells us which of the revisions to the current procedural terminology (CPT) codes have been adopted for use in the Medicare system, and how Medicare values those codes. The diagnostic radiology changes are fairly straightforward, but the interventional radiology (IR) coding for endovascular repair has been drastically altered, with 20 new or revised codes.
Diagnostic radiology
Mammography
Medicare has made the switch to the new CPT codes that were defined a few years ago. While most commercial payors stuck with the Medicare G-codes, not all of them did, and so this change should bring uniformity across all payors.
Practices should pay close attention to coding denials early in 2018 to be sure their billing aligns with the coding each payor will accept as systems are changed over. Below is the crosswalk of the codes from 2017 to 2018.
| Mammography codes | ||
| HCPCS code for 2017 | CPT code for 2018 | Descriptor |
| G0206 | 77065 | Diagnostic mammography, including computer-aided detection (CAD) when performed; unilateral |
| G0204 | 77066 | Diagnostic mammography, including CAD when performed; bilateral |
| G0202 | 77067 | Screening mammography, bilateral (2-view study of each breast), including CAD when performed |
Chest x-ray
The reporting of chest x-rays will be defined solely by the number of views taken, so only four new codes will be used, with nine codes being deleted.
| Chest x-ray codes | ||
| Description | New code | Deleted codes |
| Single view | 71045 | 71010, 71015 |
| 2 views | 71046 | 71020, 71021, 71022, 71023 |
| 3 views | 71047 | N/A |
| 4 or more views | 71048 | 71030, 71034 |
| Special views | N/A | 71035 |
Abdominal x-ray
Similarly, abdominal x-rays will be defined by the number of views taken. Three new codes were created, while 74022 for the complete acute abdomen series will remain active.
| Abdominal x-ray codes | ||
| Description | New code | Deleted codes |
| Single view | 74018 | 74000 |
| 2 views | 74019 | 74010 |
| 3 views | 74021 | 74010, 74020 |
| Complete acute abdomen series | 74022 | N/A |
The new codes are not a direct one-for-one replacement of the deleted codes due to the definitions for the old codes. According to the American College of Radiology (ACR), the U.S. Centers for Medicare and Medicaid Services (CMS) expects that 74019 will be used 25% of the time to replace 74010, while 74021 will be used 75% of the time.
Ultrasound of extremities
While the coding for these exams has not changed, the definitions of CPT 76881 and 76882 have been revised, and CMS applied a significant valuation reduction to the revised codes.
Whereas 76881 was previously called "ultrasound extremity, complete," it will now become "ultrasound complete joint." The complete study code can be used when the examination evaluates the joint space and includes the surrounding soft tissues such as tendons or nerves.
76882 will continue to be a limited exam of the joint, which means that either the joint space or the surrounding tissue was included but not both. Permanently recorded images are required to be retained under either code, and the written report must clearly describe each of the elements that were evaluated in real-time.
The CMS revaluation of 76881 was so significant that it is subject to Medicare's phase-in rule, which limits fee schedule reductions to no more than 19% in the first year.
Nuclear medicine
Nuclear medicine code 78190, "kinetics, study of platelet survival," has been eliminated due to low utilization.
Medicare billing modifier
A new modifier, "FY," will be required on Medicare claims for the technical component of diagnostic imaging services that use computed radiography (CR) rather than direct digital image processing, whether billed separately or included in the global billing. A 7% payment reduction for such services will begin in 2018 and continue through 2022. The payment reduction will become 10% beginning in 2023.
Interventional radiology
Endovascular repair procedures
For 2018, endovascular abdominal aortic aneurysm repair (EVAR) procedures will include radiologic supervision and interpretation (S&I) as an integral part of the procedure code, eliminating the ability to separately bill for the S&I codes. There are 16 new CPT codes and four codes with revised descriptions, while 14 codes were deleted.
| New and revised endovascular repair codes | |
| CPT code | Description |
| 34701 (new) | Endovascular repair of infrarenal aorta by deployment of an aorto-aortic tube endograft, for other than rupture (e.g., for aneurysm, pseudoaneurysm, dissection, penetrating ulcer) |
| 34702 (new) | Endovascular repair of infrarenal aorta by deployment of an aorto-aortic tube endograft, for rupture |
| 34703 (new) | Endovascular repair of infrarenal aorta and/or iliac artery(ies) by deployment of an aorto-uni-iliac endograft, for other than rupture (e.g., for aneurysm, pseudoaneurysm, dissection, penetrating ulcer) |
| 34704 (new) | Endovascular repair of infrarenal aorta and/or iliac artery(ies) by deployment of an aorto-uni-iliac endograft, for rupture |
| 34705 (new) | Endovascular repair of infrarenal aorta and/or iliac artery(ies) by deployment of an aorto-bi-iliac endograft, for other than rupture (e.g., for aneurysm, pseudoaneurysm, dissection, penetrating ulcer) |
| 34706 (new) | Endovascular repair of infrarenal aorta and/or iliac artery(ies) by deployment of an aorto-bi-iliac endograft, for rupture |
| 34707 (new) | Endovascular repair of iliac artery by deployment of an ilio-iliac tube endograft, for other than rupture (e.g., for aneurysm, pseudoaneurysm, dissection, arteriovenous malformation); unilateral |
| 34708 (new) | Endovascular repair of iliac artery by deployment of an ilio-iliac tube endograft, for rupture; unilateral |
| 34709 (new add-on) | Placement of extension prosthesis(es) to the common iliac artery(ies) or proximal to the renal artery(ies) for endovascular repair of infrarenal abdominal aortic or iliac aneurysm, false aneurysm, dissection, penetrating ulcer; per vessel |
| 34710 (new) | Delayed placement of distal or proximal extension prosthesis for endovascular repair of infrarenal abdominal aortic or iliac aneurysm, false aneurysm, dissection, endoleak, or endograft migration; initial vessel treated |
| 34711 (new add-on) | Each additional vessel treated |
| 34712 (new) | Transcatheter delivery of enhanced fixation device(s) to the endograft (e.g., anchor, screw, tack) |
| 34713 (new add-on) | Percutaneous access and close of femoral artery for delivery of endograft through a large sheath (12 French or larger); unilateral. This may be reported once per side. |
| 34812 (revised add-on) | Open femoral artery exposure for delivery of endovascular prosthesis, by groin incision; unilateral |
| 34714 (new add-on) | Open femoral artery exposure with creation of conduit for delivery of endovascular prosthesis or for establishment of cardiopulmonary bypass, by groin incision; unilateral |
| 34820 (revised add-on) | Open iliac artery exposure for delivery of endovascular prosthesis or iliac occlusion during endovascular therapy, by abdominal or retroperitoneal incision; unilateral |
| 34833 (revised add-on) | Open iliac artery exposure for creation of conduit for delivery of endovascular prosthesis or for establishment of cardiopulmonary bypass, by abdominal or retroperitoneal incision; unilateral |
| 34834 (revised add-on) | Open brachial artery exposure for delivery of endovascular prosthesis; unilateral |
| 34715 (new add-on) | Open axillary/subclavian artery exposure for delivery of endovascular prosthesis by infraclavicular or supraclavicular incision; unilateral |
| 34716 (new add-on) | Open axillary/subclavian artery exposure with creation of conduit for endovascular prosthesis or for establishment of cardiopulmonary bypass, by infraclavicular or supraclavicular incision; unilateral |
Note that the above codes include the following, when performed:
- All imaging guidance and monitoring
- All associated radiological supervision and interpretation
- All preprocedure sizing and device selection
- All nonselective catheterization(s)
- All endograft extension(s) placed in the aorta from the level of the renal arteries to the aortic bifurcation
- All angioplasty/stenting performed from the level of the renal arteries to the aortic bifurcation
- Temporary aortic and/or iliac balloon occlusion (e.g., for aneurysm, pseudoaneurysm, dissection, arteriovenous malformation, traumatic disruption)
| Deleted endovascular repair codes | |
| CPT code | Description |
| 34800 | Endovascular repair of infrarenal abdominal aortic aneurysm or dissection; using aorto-aortic tube prosthesis |
| 34802 | Using modular bifurcated prosthesis (1 docking limb) |
| 34803 | Using modular bifurcated prosthesis (2 docking limbs) |
| 34804 | Using unibody bifurcated prosthesis |
| 34805 | Using aorto-uni-iliac or aorto-uni-femoral prosthesis |
| 34806 | Transcatheter placement of wireless physiologic sensor in aneurysmal sac during endovascular repair |
| 34825 | Placement of proximal or distal extension prosthesis for endovascular repair of infrarenal abdominal aortic or iliac aneurysm, false aneurysm, or dissection; initial vessel |
| 34826 | Each additional vessel |
| 34900 | Endovascular repair of iliac artery using ilio-iliac tube endoprosthesis |
| 75952 | Radiological S&I for endovascular repair of infrarenal abdominal aortic aneurysm or dissection |
| 75953 | Radiological S&I for placement of proximal or distal extension prosthesis for endovascular repair of infrarenal aortic or iliac artery aneurysm, pseudoaneurysm |
| 75954 | Radiological S&I for endovascular repair of iliac artery aneurysm, arteriovenous malformation, or trauma, using ilio-iliac tube endoprosthesis |
| 93982 | Noninvasive physiologic study of implanted wireless pressure sensor in aneurysmal sac following endovascular repair |
A complete review of the usage of the revised endovascular repair coding is beyond the scope of this article.
Treatment of pulmonary tumors
The addition of CPT code 32994 differentiates cryoablation of pulmonary tumors from radiofrequency ablation (CPT 32998), and it replaces the category III code 0340T that was previously used.
Both codes include imaging guidance with the basic procedure, eliminating the ability to separately bill for the guidance codes. Also note that both are unilateral.
Treatment of incompetent veins
Revision of the three existing injection codes (36468, 36470, and 36471) makes a distinction between treatment for spider veins (telangiectasia) and for all other diagnoses. Four new codes were added to report newer methods of treating incompetent veins. The 2018 codes for these procedures are described below.
| Codes for treatment of incompetent veins | |
| CPT code | Description |
| 36465 (new) | Injection of noncompounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate; single incompetent extremity truncal vein |
| 36466 (new) | Multiple incompetent extremity truncal veins (same leg) |
| 36468 (revised) | Injection of sclerosant for telangiectasia; limb or trunk |
| 36470 (revised) | Injection of sclerosant for other than telangiectasia; single incompetent vein |
| 36471 (revised) | Multiple incompetent veins (same leg) |
| 36482 (new) | Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (e.g., cyanoacrylate) remote from the access site, percutaneous; first vein treated |
| 36483 (new) | Subsequent vein(s) treated in a single extremity, each through separate access sites |
The above codes include all imaging guidance and monitoring.
Bone marrow procedures
CPT codes 38220 (aspiration only) and 38221 (biopsy by needle or trocar) describing the aspiration of bone marrow have been revised to specify that these are diagnostic procedures. When a procedure is both an aspiration and a biopsy, the new code 38222 is to be used. Another new add-on code is available, CPT 20939 -- "bone marrow aspiration for bone grafting, spine surgery only, through separate skin or fascial incision," when appropriate.
Brachial artery catheter insertion
Two codes describing the introduction of a needle or intracatheter into an artery have been combined into one code. CPT 36120 has been eliminated, and 36140 has been revised to include either the retrograde brachial artery or an extremity artery, whether upper or lower extremity. Angiography brachial retrograde S&I code 75658 has also been eliminated.
Miscellaneous code changes
The category III codes in the table below have been removed or revised as noted.
| Other code changes | ||
| Code | Description | Comment |
| 0255T | Radiologic S&I for endovascular repair of iliac artery bifurcation using bifurcated endoprosthesis from the common iliac artery into both the external and internal iliac artery; unilateral | Deleted, refer to code 0254T |
| 0254T | Endovascular repair of iliac artery bifurcation using bifurcated endoprosthesis from the common iliac artery into both the external and internal iliac artery; unilateral | Revised to include all radiological S&I |
| 0340T | Ablation of pulmonary tumors, including pleura or chest wall when involved by tumor extension, percutaneous, cryoablation, unilateral | Replaced by CPT 32994 |
| 0438T | Transperineal placement of biodegradable material, periprostatic (via needle), single or multiple | New CPT code to be issued |
| 0042T | Cerebral perfusion analysis using CT with contrast administration, including postprocessing of parametric maps with determination of cerebral blood flow, cerebral blood volume, and mean transit time | Will be extended |
Conclusion
While CMS expects that the impact of all changes to the MPFS will be small for diagnostic and interventional radiology, each practice's experience will vary based on the volume of procedures that use the affected codes. A volume-weighted analysis of the entire Medicare Physician Fee Schedule is recommended to gain a complete understanding of the effect on practice revenue.
Note that commercial payors might not adopt all of the same coding changes as Medicare does, and it is impossible to summarize here the effect on their payment policies. This is especially true for non-CPT codes such as the G-codes for mammography.
Rebecca Farrington serves as chief revenue officer for Healthcare Administrative Partners. She has more than 20 years of experience in healthcare sales and management roles, focusing on hospital-based and physician revenue cycle management.
The comments and observations expressed herein are those of the author and do not necessarily reflect the opinions of AuntMinnie.com.
