CPT 2018: What's new, part 2
Cracking the Code
Dr. Miller, who is in private practice in Yorba Linda, California, represents the American Academy of Dermatology on the AMA-CPT Advisory Committee.
By Alexander Miller, MD, January 1, 2018
In addition to the reconfigured photodynamic therapy codes discussed in the preceding issue of Cracking the Code, the 2018 Current Procedural Terminology (CPT®) manual includes several new codes relevant to dermatology. These are both Category I and Category III CPT codes.
Category III codes
You can easily identify a Category III code by its specific alphanumeric format: four numbers followed by the letter T, as in 0394T, which identifies high dose rate electronic skin surface brachytherapy treatment.
Category III codes are temporary codes defining emerging technology, procedures, and services that do not meet Category I criteria but are sufficiently distinct so as to merit a code descriptor. These codes characterize services or procedures that are already being performed but previously either lacked a dedicated code or had a Category III code that has been redefined. These codes are not permanent. Some of them may eventually ascend to Category I status. Others may be redefined yet remain within the Category III realm. Unchanged codes in this section are archived after five years.
Why is it important to use designated Category III codes? First, if such a code is available and describes a specific procedure or service, then per CPT instructions, that code should be used. From a practical standpoint, the repeated use of such codes yields data on code utilization to insurers, policymakers, and the CPT process, thereby enhancing the possibility that such a code would ultimately be elevated to a Category I or become an insurance covered entity. Category III status does not predict denial of coverage/payment from insurers. Select Category III codes, such as the electronic skin surface brachytherapy code, 0394T, are reimbursed by some insurers. On the other hand, unlisted procedure Category I codes such as 96999 (unlisted special dermatologic service or procedure) or 17999 (unlisted procedure, skin, mucous membrane and subcutaneous tissue) are rarely, if ever, reimbursed without a protracted appeals process.
New Category III codes for 2018 are:
0470T Optical coherence tomography (OCT) for microstructural and morphological imaging of skin, image acquisition, interpretation, and report; first lesion
0471T each additional lesion (List separately in addition to code for primary procedure)
These codes should not be confused with reflectance confocal microscopy (RCM), CPT 96931-96936.
0479T Fractional ablative laser fenestration of burn and traumatic scars for functional improvement; first 100 cm2 or part thereof, or 1 percent of body surface area of infants and children
0480T each additional 100 cm2, or each additional 1 percent of body surface area of infants and children, or part thereof (List separately in addition to code for primary procedure)
The laser fenestration codes are specific for treating broad areas of constricting scars that restrict motion. Such scars most commonly result from extensive traumatic injuries and burns, such as those suffered in war and fires. The ablative laser treatments can significantly enhance movement and function. These codes, for treating traumatic scars, are distinguished from ablative laser treatments of open wounds, described by codes 0491T and 0492T.
Category I codes: Pedicle flaps
The 2018 CPT also includes a significant revision of the category I pedicle flap code series. Code 15732, which specified muscle, myocutaneous, or fasciocutaneous flaps of the head and neck, has been deleted and replaced with a new code:
15733 Muscle, myocutaneous, or fasciocutaneous flap; head and neck with named vascular pedicle (ie, buccinators, genioglossus, temporalis, masseter, sternocleidomastoid, levator scapulae)
The previously deleted 15732 and the new 15733 codes are not interchangeable in their meaning and use. Code 15733 is not appropriate for characterizing the more common dermatologic reconstructive procedures that may involve moving an island of cutaneous tissue based upon an underlying attached muscle; use adjacent tissue rearrangement codes CPT 14060 or 14061 instead. Code 15733 stipulates that the flap has to have a named blood vessel pedicle.
Another addition to the pedicle flaps series is:
15730 Midface flap (ie, zygomaticofacial flap) with preservation of vascular pedicle(s)
The above flap is likely to be rarely used by dermatologists. Both the 15730 and 15733 codes describe procedures that will characteristically be done in facility settings.
Example 1: You fractional laser ablate a 100 sq cm contracted scar on the right hand and then proceed to ablate another, 81 sq cm scar on the antecubital fossa. As these are anatomically distinct areas, you code with CPT 0479T twice, once for the hand, and once for the antecubital fossa.
Answer: Incorrect. The fractional ablative laser fenestration codes are to be used once per day of service. Consequently, correct coding is: 0479T for the first 100 sq cm treated, and 0480T for the additional 81 sq cm treatment.
Example 2: Following an excision of a basal cell carcinoma located on the distal nose, you repair the defect with a myocutaneous flap based upon the transverse nasalis muscle. Since you know that the transverse nasalis muscle is typically nourished by the lateral nasal artery, a branch of the angular artery, you select CPT 15733 to code for the procedure.
Answer: Incorrect. Code 15733 is intended for flaps based upon large muscles and a defined, named vascular pedicle. This does not apply to the nasalis muscle. The procedure is appropriately coded with an adjacent tissue rearrangement code, CPT 14060 or 14061.
Example 3: You repair a large dorsal nasal defect with a paramedian forehead flap. You select code 15731 to describe your work.
Answer: Correct. CPT code 15731, forehead flap with preservation of vascular pedicle (eg, axial pattern flap, paramedian forehead flap) remains unchanged for 2018.
Example 4: A Mohs surgical defect involving the ala nasi is repaired with an interpolation flap generated from the cheek. Code 15576 is selected to characterize the procedure. You report the PDT with CPT 96574 and the biopsy with 11100.
Answer: Correct. Codes 15570-15576, which describe direct or tubed pedicles attached to recipient sites, are not changed for 2018. When an interpolation flap is attached to a final recipient site the appropriate code is selected based upon the location of the repaired defect, in this case the nose. However, if a pedicle is formed but attached to a final recipient site at a later date, the location of the pedicle (donor site) is used for appropriate code selection. Interpolation flap division and inset, which is commonly done 2-3 weeks after the original flap placement, is coded with CPT 15600-15630, with code selection based upon the location of the inset flap (in this example, the nose).
