AMA 2023 CPT Code Changes -Industry News, September 2022

AMA 2023 CPT® Code Changes

The American Medical Association (AMA) released the 2023 CPT® code set on September 9, 2022. This code set expands upon the long-awaited modifications to E/M for inpatient and observation care services, consultations, emergency department services, nursing facility services, home and residence services and prolonged services, as well as several other highly anticipated changes.

AMA states the 2023 CPT® code set contains burden-reducing revisions to both the codes and guidelines in attempt to make documentation easier and more flexible for other E/M services. The goal for the burden-reduction documentation is to free physicians and care teams from clinically irrelevant tasks to save time while still providing high-quality patient care.

A total of 393 editorial changes were made for the 2023 code set, including 225 new codes, 75 deletions, and 93 revisions.

In addition to the revisions, a new appendix has also been added to the 2023 CPT® code set which includes a taxonomy for artificial intelligence/augmented intelligence (AI) applications. The newly created AI taxonomy provides classification and guidance for a wide range of AI-powered applications, such as expert systems, machine learning, or algorithm-based solutions. The AI-powered applications are divided into three categories: assistive, augmentative, or autonomous.

ACR Changes Requirements, Allows Non-Physician Practitioners to Supervise Contrast Studies

The American College of Radiology (ACR) has updated its accreditation requirements, authorizing accredited MRI and CT imaging centers to allow supervision of contrast-enhanced studies by mid-level practitioners.

The ACR had updated its practice parameter for the use of intravascular contrast in May. This change to the accreditation program aligns with the guidance provided in the practice parameter, under which radiologists (MD/DO) may provide direct supervision of IV contrast administration.

Additionally, under the general supervision of a radiologist, non-radiologist physicians, advanced registered nurse practitioners, physician assistants, and registered nurses following a symptom- and sign-driven treatment algorithm may also provide direct supervision of IV contrast administration.

The ACR reminds practitioners that all state and local regulations for supervision of contrast administration still apply and must be followed.

WPS TPE Quarter 2 Findings Released

Wisconsin Physician Services (WPS) has released the quarter 2 (Q2) Targeted Probe and Educate (TPE) findings. WPS’ Medical Review team recently found an error rate of 81% – 99% when billing infusion services represented by CPT® codes 96413 – Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug; and 96415- Chemotherapy administration, intravenous infusion technique; each additional hour (List separately in addition to code for primary procedure). The main reason for denial was the lack of supporting documentation of frequent monitoring. Since there is a higher probability of adverse effects associated with chemotherapy or other drug or biologic agent administration, the clinical monitoring of a patient receiving the infusion should have increased monitoring compared to that of a therapeutic drug. Supporting documentation to support frequent monitoring, as outlined by WPS, could include:

  • Treatment flowsheets indicating vital sign monitoring, intravenous (IV) site check, and/or infusion rate change
  • Progress notes of patient condition in objective times

Additional findings of the second quarter TPE identified a 53% error rate for infusion services represented by CPT® code 96361 – Intravenous infusion, hydration; each additional hour (List separately in addition to code for primary procedure). Denials for the infusion service were based on documentation supporting intravenous (IV) fluids for the purpose of keeping a vein open. WPS reiterates CPT® coding guidelines which indicate providers should not bill code 96360 and 96361 when the purpose of the fluids is to keep open a vein.

AMA, Other Health Care Organizations Urge Senate to Extend Telehealth Flexibilities

In a letter to senators last week, the American Medical Association (AMA), along with over 300 other physician, health care, and patient organizations, asked the Senate to extend pandemic telehealth flexibilities for at least two years following the existing statutory extension at the end of the public health emergency (PHE).

Telehealth access “has been transformational—patients now expect and often prefer telehealth as a key component of our health care system,” the organizations said in the letter addressed to Senate Majority and Minority Leaders Chuck Schumer and Mitch McConnell.

When the COVID public health emergency (PHE) ends, the flexibilities and waivers allowing increased access to telehealth will persist for 151 days, and then are set to expire. The health care organizations urged the Senate to join the House in passing the Advancing Telehealth Beyond COVID-19 Act (H.B. 4040), which would extend telehealth flexibilities for two-years and allow Congress to continue pushing for a permanent extension “that includes provisions to lift provider and patient location limitations, remove in-person requirements for telemental health, ensure continued access to clinically appropriate controlled substances without in-person requirements, and increase access to telehealth services in the commercial market.”

FDA Allows Orphan Drug Designation for Bispecific Antibody for Pancreatic Cancer

ATG-101 (Antengene), a novel PD-L1/4-1BB bispecific antibody used in the treatment of pancreatic cancer, has been granted orphan drug designation (ODD) by the U.S. Food and Drug Administration (FDA).

Bo Shan, PhD, chief scientific officer of Antengene, stated, “[We] are hopeful that ATG-101 will offer a novel therapeutic to patients with pancreatic cancer … We will strive to accelerate the global clinical development of ATG-101 in efforts to provide a new treatment option to patients around the world.”

The FDA grants orphan drug designation to certain novel drugs and biologics “intended for the safe and effective treatment, diagnosis, or prevention of rare diseases or disorders that affect fewer than 200,000 people in the United States.” As a result of this designation, Antengene will receive benefits such as monetary incentives for clinical development and up to 7 years of market exclusivity (with regulatory approval).

AHA, AMA Withdraw Lawsuit Over No Surprises Act

The American Hospital Association (AHA) and the American Medical Association (AMA) have withdrawn their legal challenge to the No Surprises Act’s independent dispute resolution process.

The lawsuit, filed in December 2021 (following the release of the September 2021 interim final rule), aimed to revise regulations pertaining to dispute negotiations between payers and providers. However, the organizations said the revised final rule released in August 2022 rendered their existing lawsuit no longer relevant.

In a joint statement, the AHA and AMA said: “We have serious concerns that the August 2022 final rule departs from congressional intent just as the September 2021 interim final rule did … Hospitals and doctors intend to make our voices heard in the courts very soon about these continued problems.”

Researchers Ask Questions About CMS Shared-Decision Making for CT Lung Cancer Screening

In the August edition of the Journal of the American College of Radiology (JACR), four physicians asked pointed questions regarding the Centers for Medicare and Medicaid Services (CMS) policy of requiring clinicians to document that they shared decision-making regarding CT lung cancer screening with the patient.

In the opinion paper, authored by Jennifer Lewis, MD, MPH; Lucy Spalluto, MD, MPH (both of Vanderbilt University Medical Center); Renda Soylemez Weiner, MD, MPH (Boston University Medical Center); and Christopher Slatore, MD (Oregon Health and Science University), the physicians expressed concerns that the current CMS policy may prevent suitable candidates from accessing potential life-saving low-dose CT scans and asked the following questions:

  1. Is the CMS Policy That Requires Documenting Shared Decision-Making Working?
  2. What Shared Decision-Making Documentation Is Currently Required by CMS for Reimbursement?
  3. Should We Do Shared Decision-Making, and If So, How Should Shared Decision-Making Be Documented?
  4. How Can We Improve Shared Decision-Making and Utilization of High-Quality Lung Cancer Screening?

“Current CMS policies mandating lung cancer screening shared decision-making documentation are a potential barrier to screening utilization,” the authors stated. “Adapting the current shared decision-making model to a more practical and meaningful opportunity for patient-clinician communication may increase utilization of high-quality lung cancer screening and improve screening equity.”
Lung cancer is the leading cause of cancer death in the United States.

New NCCI Edits: Abdominal and Retroperitoneal US

Beginning October 1, a modifier will need to be appended when abdominal US (76700-76705) and retroperitoneal US (76770-76775) are reported on the same date of service. New edits can be viewed here.