A single new code (32408) has been created to describe percutaneous core needle biopsy of the lung or mediastinum. Since this procedure is commonly performed with imaging guidance, this code includes imaging guidance when used to perform the biopsy, regardless of the number of modalities used. Therefore, do not report 76942, 77002, 77012 or 77021 with 32408. Note that CPT 32405 has been deleted.
32408 may be reported only once per lesion, regardless of the number of needle passes or samples required to obtain a diagnosis. However, if separate lesions of the lung or mediastinum are biopsied in the same session, 32408 can be reported per lesion biopsied. A modifier -59 should be appended to each additional lesion reported.
This code is specific to core needle biopsy with intent of histopathologic evaluation. If fine needle aspiration (FNA; with intent of cytologic evaluation) is also performed in the same session, one can report both core biopsy code and FNA code. Depending on the combination of modalities used and lesions biopsied, modifiers will need to be appended to coding. See the SIR 2021 Annual Coding Update for additional guidance on combination of services reported in the same session.
32408 Core needle biopsy, lung or mediastinum, percutaneous, including imaging guidance, when performed.
Category III codes
There are a number of new Category III codes. Category III codes are temporary codes used to describe a procedure or service that may be described as a “new and emerging technology.” These codes are created when there may not be enough supporting literature or utilization data demonstrating widespread use to support a Category I code. Category III codes can be used to track data on the usage of the service for future determinations. Category III codes do not have an assigned RVU value and are typically “carrier priced,” therefore reimbursement will be variable.
While not widely used, here are some new Category III codes that were created for 2021 that may be of interest to your practice:
0600T Ablation, irreversible electroporation; one or more tumors per organ, including imaging guidance, when performed, percutaneous.
0601T Ablation, irreversible electroporation; one or more tumors per organ, including fluoroscopic and ultrasound guidance, when performed, open.
0620T 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, all associated radiological supervision and interpretation, when performed.
Office or other outpatient evaluation and management coding changes
The AMA has issued a new set of guidelines to be used when determining the appropriate level of service (LOS) for outpatient evaluation and management services (E&M). These guidelines are specific to new and established outpatient services only (99201–99205 and 99211–99215, respectively). These newly established guidelines do not change how an LOS is chosen for other E&M services (e.g., inpatient, observation, consultations). Note that CPT 99201 (level one, new patient service) has been deleted.
These changes were put in place with the intention of easing the documentation burden on providers and, in turn, providing higher quality, more clinically relevant documentation in the patient medical record.
There is no longer a requirement to perform and document a full (complete) history and physical exam. Now, the history reviewed and any physical exams performed only need be pertinent to the encounter, as determined by the treating provider. The key determining factors that can be used in 2021 to determine your level of service are either medical decision making (MDM) or time-based criteria. Extensive guidelines were added to the 2021 CPT® manual outlining how either of these factors would be used. Below are a few important fundamentals to note.
Elements that are considered when using MDM for determining LOS:
The number of and complexity of problems addressed in the encounter
The amount and/or complexity of the information reviewed and analyzed
The risk of complications and/or morbidity or mortality in patient management
Using time when determining LOS:
A face-to-face encounter must occur between the patient and a physician or qualified healthcare provider when using time as the determining factor.
Time can now be used regardless of whether or not the time spent counseling and/or coordinating care dominated the service.
Time is calculated by total cumulative time spent on the date of the encounter only (not time spent on days leading up to or after the date of the encounter).
Total time includes face-to-face time, as well as certain elements of non-face-to-face time of the provider (not clinic staff), such as:
Preparing to see patient in reviewing chart (e.g., labs, prior imaging, previously documented history, etc.)
Ordering medications, tests or procedures
Communicating with other healthcare professionals
Documenting clinical information in the health record
Care coordination
Additionally, if reporting LOS using time as the determining factor, one could report CPT 99417 for prolonged service. To report 99417, the time must exceed the maximum required time of the primary service that is reported. CPT 99417 is considered an add-on code to CPT 99205 or 99215 only and is reported for each additional 15 minutes of total time performed on the date of the encounter. These prolonged service codes can only be used when time itself is solely used as a basis for primary service reporting.
Office/outpatient service for new patient
99201 has been deleted. To report, use 99202
99202 Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making.
When using time for code selection, 15–29 minutes of total time is spent on the date of the encounter.
99203 Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making.
When using time for code selection, 30–44 minutes of total time is spent on the date of the encounter.
99204 Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making.
When using time for code selection, 45–59 minutes of total time is spent on the date of the encounter.
99205 Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making.
When using time for code selection, 60–74 minutes of total time is spent on the date of the encounter.
Office/outpatient service for established patient
99211 Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal.
99212 Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making.
When using time for code selection, 10–19 minutes of total time is spent on the date of the encounter.
99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making.
When using time for code selection, 20–29 minutes of total time is spent on the date of the encounter.
99214 Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making.
When using time for code selection, 30–39 minutes of total time is spent on the date of the encounter.
99215 Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making.
When using time for code selection, 40–54 minutes of total time is spent on the date of the encounter.
Prolonged service with or without direct patient contact on date of office or outpatient service
+ 99417 Prolonged office or other outpatient evaluation and management service(s) beyond the minimum required 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 of total time. (List separately in addition to codes 99205, 99215 for office or other outpatient E&M services).
The SIR Coding and Reimbursement team is here to support you. If you have any coding questions, please submit them to tfaforms.com/447124.
Disclaimer: SIR is providing this billing and coding guide for educational and information purposes only. It is not intended to provide legal, medical or any other kind of advice. The guide is meant to be an adjunct to the American Medical Association’s (AMA’s) Current Procedural Terminology (2021/CPT®). It is not comprehensive and does not replace CPT. Our intent is to assist physicians, business managers and coders. Therefore, a precise knowledge of the definitions of the CPT descriptors and the appropriate services associated with each code is mandatory for proper coding of physician service. Please refer to 2021 CPT® for full and complete guidelines.
Every reasonable effort has been made to ensure the accuracy of this guide; but SIR and its employees, agents, officers and directors make no representation, warranty or guarantee that the information provided is error-free or that the use of this guide will prevent differences of opinion or disputes with payers. The publication is provided “as is” without warranty of any kind, either expressed or implied, including, but not limited to, implied warranties or merchantability and fitness for a particular purpose. The company will bear no responsibility or liability for the results or consequences of the use of this manual. The ultimate responsibility for correct use of the Medicare and AMA CPT billing coding system lies with the user. SIR assumes no liability, legal, financial or otherwise for physicians or other entities who utilize the information in this guide in a manner inconsistent with the coverage and payment policies of any payers, including but not limited to Medicare or any Medicare contractors, to which the physician or other entity has submitted claims for the reimbursement of services performed by the physician.
