New vs Established Patient

Question:

I am a contracted physician with a group practice (Practice A) in our town. I have an opportunity to contract with another practice (Practice B) not in the same town, but near enough that my patients could see me in either location. My question has to do with the definition of new and established patients. If I see a patient in Practice A and that patient sees me in Practice B, is that the encounter in Practice B a new patient encounter?

Answer:

Thanks for your inquiry and this question is one that is sometimes confusing or where the new practice may not like to hear the answer.
Assuming the patient from Practice A sees you in Practice B within three years of the encounter in Practice A, it is an established patient encounter for you. The same holds true if you first see the patient in Practice B and the patient follows up with you in Practice A within the three year period.
In the June 1999 edition of CPT Assistant (Q&A included below), the AMA also extended the limitation to partners in practice A, meaning if the patient saw you or a partner in Practice A, and saw you in practice B within a three year period, the patient would be established to you, even in a different group.

“Changing Group Practices
What about the physician who leaves one group practice and joins a different group practice elsewhere in the state? Consider Dr A who leaves his group practice in Frankfort, Illinois and joins a new group practice in Rockford, Illinois. When he provides professional services to patients in the Rockford practice, will he report these patients as new or established?
If Dr A, or another physician of the same specialty in the Rockford practice, has not provided any professional services to that patient within the past three years, then Dr A would consider the patient a new patient. However, if Dr A, or another physician of the same specialty in the Rockford practice, has provided any professional service to that patient within the past three years, the patient would then be considered an established patient to Dr A. Remember, the definitions include professional services rendered by other physicians of the same specialty in the same group practice.”

Something else to consider:
The following comment is not related to your inquiry but one to consider. If a patient from Practice A has a surgical procedure with a 90 day global period, KZA recommends all follow-up care be performed in Practice A, as this practice was reimbursed for the surgical procedure. If the patient is instead seen in follow-up in Practice B during the global period, 99024 must be reported and there is no reimbursement to Practice B to offset expenses for that encounter.

Category III Codes Effective July 1, 2022

Question:

I  heard someone say the 2022 CPT manual will be updated in July with new codes. I have never heard of this before. Is this a rumor or will there be a new CPT Manual released in July?

Answer:

No, there will not be any changes to the 2022 AMA CPT Manual in July.

The following AMA Category III Codes become effective July 1, 2022 and will be identified as new codes in CPT 2023.

Beginning July 1, report the Category III code when appropriate, in place of an unlisted code.

Category III Code	Description	Effective Date	CPT Publication
Ÿ0717T	Autologous adipose-derived regenerative cell (ADRC) therapy for partial thickness rotator cuff tear; adipose tissue harvesting, isolation and preparation of harvested cells, including incubation with cell dissociation enzymes, filtration, washing and concentration of ADRCs Guidelines: Ø (Do not report 0717T in conjunction with 15769, 15771, 15772, 15773, 15774, 15876, 15877, 15878, 15879, 20610, 20611, 76942, 77002, 0232T, 0481T, 0489T, 0565T) ×	7/1/2022	1/1/2023
Ÿ0718T	injection into supraspinatus tendon including ultrasound guidance, unilateral Guidelines: Ø (Do not report 0718T in conjunction with 20610, 20611, 76942, 77002, 0232T, 0481T, 0490T, 0566T)×	7/1/2022	1/1/2023
Ÿ0719T	Posterior vertebral joint replacement, including bilateral facetectomy, laminectomy, and radical discectomy, including imaging guidance, lumbar spine, single segment Guidelines: Ø (Do not report 0719T in conjunction with 22840, 63005, 63012, 63017, 63030, 63042, 63047, 63056, 76000, 76496) ×	7/1/2022	1/1/2023
Ÿ0720T	Percutaneous electrical nerve field stimulation, cranial nerves, without implantation	7/1/2022	1/1/2023
Ÿ0737T	Xenograft implantation into the articular surface Guidelines Ø (Use 0737T once per joint) × Ø (Do not report 0737T in conjunction with 27415, 27416) ×	7/1/2022	1/1/2023

Knee Ligament Repair vs Reconstruction

Question:

What type of graft or fixation material is required to report open extra-articular knee ligament reconstruction code 27427? Our physician is listing “MCL repair” and “MCL reconstruction” within the same operative note. It first describes repair of the ligament using Suture Tape. In a separate paragraph the physician describes insertion of additional Tape, but calls the work “reconstruction”.

Answer:

Reconstruction CPT codes are used when biologic tissue is used to replace insufficient, nonfunctioning, or missing native tissue. The replacement biologic tissue may be an autograft (harvested from the patient) or an allograft (harvested from a cadaver). In this example the physician is using additional Suture Tape to supplement or protect the repair; that is not considered reconstruction.

Fee Setting: Category III Codes or Unlisted Procedures

Question:

We are looking at CPT code 0707T for reporting subchondroplasty in our practice. We have never billed a Category III code and do not know how to set the fee.

Answer:

Setting the fee for the Category III code will follow the same methodology as an unlisted procedure code. KZA recommends including the surgeon in the discussion to ensure the most appropriate CPT code is selected as the comparison code. Here are some considerations:

1. Choose a code similar to the Category III procedure (or unlisted procedure) you performed. This includes the approach and anatomic location, if possible. This will be your “base code” or “comparison” code.
2. List 2–3 things that make the Category III (or unlisted) procedure more or less difficult than the comparison CPT code.
3. Assess the RVUs of the similar code, making sure you feel it represents a fair value for the work involved. If it does not, continue looking.
4. Convert the greater or lesser degree of difficulty to a % increase or decrease in your fee for the comparison code. This becomes the fee for your Category III (or unlisted) code.
5. Report the appropriate Category III (or unlisted) code on the claim form linked to the appropriate diagnosis. Either in box 19 or on the same line, identify the comparison CPT code and the name of the procedure performed. This provides the payor information to hopefully process the claim the first time.
6. If the payor allows it, submit the operative note electronically with the claim.

We hope this helps you and your surgeon arrive at the most appropriate comparison code.

Teaching Physician Rules Related to E&M Code Selection

Question:

We are an academic orthopaedic practice with an orthopaedic GME-approved residency program in a large metropolitan city. We were just informed we have been incorrectly reporting E&M codes 99202-99215 to Medicare since January 2022.

We select the level of service based on MDM or time, as we understood this to be correct. We were told we should not be reporting Medicare E&M services based on time and must use MDM only when coding E&M services.

Have we been coding incorrectly when using time versus MDM when time better supports the level of service? We do not include resident time or resident education when calculating time.

Answer:

Thanks for your inquiry. There was a change in the Medicare Teaching Physician Rules related to E&M code selection effective January 2022; however, the changes would not apply in your specialty. The rules apply to a setting where the primary care exception applies. To read more on the primary care exception and where it may apply in your academic setting, visithttps://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/teaching-physicians-fact-sheet-icn006437.pdf

Perhaps this citation from a Medicare MAC was interpreted incorrectly, hence, the information you received.

New Medicare requirements on documenting E/M services by teaching physicians – effective January 1
Exception for evaluation and management (E/M) services in certain primary care centers
Effective January 1, teaching physicians may use only medical decision making (MDM) for purposes of E/M visit level selection when billing the Medicare program under the physician fee schedule for office/outpatient E/M visits via a primary care exception.

Time-Based Codes
Additional updates apply to office/outpatient E/M visit codes for which total time is used for the visit level selection. For purposes of selecting the visit level, only count time spent by the teaching physician performing qualifying activities listed by CPT (with or without direct patient contact on the date of the encounter), including the time the teaching physician is present when a resident is performing such activities.

Grafts/Implants

Question:

I know in years past from attending KZA/ AAOS workshops that the instructors taught that bone grafts (CPT code 20900 and 20902) were only reportable if the graft was harvested via a separate incision. Our surgeon recently did an arthroplasty procedure and harvested local bone to fill in bone voids. The surgeon wanted to code separately and I told the surgeon about needing to have made a separate incision. Now, I am questioning myself and wondering if this is still correct?

Answer:

Yes, you are correct.  CPT continues to provide guidelines for Grafts/Implants that may be found in the 2022 CPT Manual Professional Edition on page 147.

The instructions address reporting services when obtaining autogenous bone, cartilage, fascia lata, bone marrow or other tissues. The instructions state a separate CPT code should be reported when the graft/implant is harvested via separate skin/fascial incisions. An exception applies when the CPT code descriptor references the harvest of a graft as included in the code.

This section of CPT applies to CPT codes 20900, 20902, 20910, 20912, 20920, 20922, and 20924.

CPT codes 20900 and 20902 are described as:

20900: Bone graft, any donor area; minor or small (eg, dowel or button)

20902:   Bone graft, any donor area; major or large

An exception applies when the CPT code descriptor references the harvest of a graft as included in the code.

Two examples of CPT codes where the descriptor states “includes obtaining graft” follow:

25274: Repair, tendon or muscle, extensor, forearm and/or wrist; secondary, with free graft (includes obtaining graft), each tendon or muscle

25431: Repair of nonunion of carpal bone (excluding carpal scaphoid (navicular)) (includes obtaining graft and necessary fixation), each bone

The harvest of the graft (tendon (20924) or bone (20900, 20902)) is inclusive regardless of whether obtained via the same or separate incision.  A tendon graft or bone graft code is not separately reportable with these two primary codes.

Different rules apply to the other CPT codes 20930-20939, 20932-20934 that are also found in this section of CPT.