Part 4: New 2020 CPT Codes | Digestive, Urinary, Nervous, Ocular, Auditory Systems

This is Part 4 of a five part series on the new 2020 CPT codes. In this series we will explore the CPT changes for FY 2020 and include examples to help the coder understand the new codes. 

This series includes:

• Part 1 - 5 new integumentary CPT codes added with 4 deletions and 1 revision.
• Part 2 - 11 new musculoskeletal CPT codes added with 1 deletion and 0 revisions.
• Part 3 - 11 new cardiovascular CPT codes added with 8 deletions and 2 revisions.
• Part 4 - 3 new digestive system codes with 1 deletion and 2 revised; 1 revised urinary system codes with new category III codes; 6 new with 20 deleted nervous system codes with 3 revisions; 2 new eye codes with 3 revisions; and finally a new category III auditory code.
• Part 5 - summary of Modifiers, Category III codes, Radiology, Medicine, Laboratory and Pathology, and Evaluation and Management.

Digestive System – Hemorrhoidectomy and Pelvic Exploration

There has been two revised codes for internal hemorrhoidectomy to denote without imaging guidance and one new code for internal hemorrhoidectomy via trans anal dearterialization:

▲46945 Hemorrhoidectomy, internal, by ligation other than rubber band; single hemorrhoid column/group, without imaging guidance

▲46946 Hemorrhoidectomy, internal, by ligation other than rubber band; 2 or more hemorrhoid columns/groups, without imaging guidance

• 46948 Hemorrhoidectomy, internal, by trans anal hemorrhoidal dearterialization, 2 or more hemorrhoid columns/groups, including ultrasound guidance, with mucopexy, when performed

Code 46948 had been category III code 0249T which has been deleted.

Dearterialization is ligating all arteries leading to the hemorrhoid column to decrease the blood flow to them.  Mucopexy is a ring of sutures to pull-up a prolapse.  If dearterialization is of a  single hemorrhoid column/group only, assign 46999. 

Two new codes were created for pelvic exploration for pelvic trauma:

• 49013 Preperitoneal pelvic packing for hemorrhage associated with pelvic trauma, including local exploration
• 49014 Re-exploration of pelvic wound with removal of preperitoneal pelvic packing, including repacking, when performed

Created for preperitoneal pelvic packing for hemorrhage associated with pelvic trauma.

These codes differ from other exploration procedures in that a laparotomy is not performed. Instead a low-horizontal Pfannenstiel incision is made just above the pubic rim, with dissection carried out until the urinary bladder is identified, without opening up the peritoneum.  The re-exploration code is used if there is need for repacking or there is continued bleeding that needs repacking.

Urinary/Reproductive Systems – Orchiopexy Revision, Ablation of Prostate, Balloon Continence Device, Fallopian Tube Occlusion

Code 54640 was revised as below: 

▲ 54640 Orchiopexy, inguinal or scrotal approach with or without hernia repair scrotal approach

This code was adjusted to remove the approach and the hernia repair reference.  The “with or without hernia repair” conflicted with the intention to allow separate reporting of inguinal hernia repair when performed as instructed.  Both inguinal and scrotal approaches are typical.

• 0582T Transurethral ablation of malignant prostate tissue by high-energy water vapor thermotherapy, including intraoperative imaging and needle guidance.

When the vapor needle location is confirmed, then periprostatic saline infusion is done followed by vapor delivery into the target at standard setting of 400 calories per vapor treatment is performed, ablating the malignant prostate tissue.

Four new codes were created for Transperineal balloon continence devices:

• 0548T Transperineal periurethral balloon continence device; bilateral placement, including cystoscopy and fluoroscopy
• 0549T … unilateral placement, including cystoscopy and fluoroscopy
• 0550T … removal, each balloon
• 0551T … adjustment of balloon(s) fluid volume

Current codes exist for insertion, removal, replace and repair of artificial urinary sphincter.  More codes exist for placement removal and revision of male mesh sling.

The above procedure involves scout cystoscopy, filling of bladder with contrast and saline, prime adjustable continence device with isotonic solution, the two incisions on either side of midline of perineum, placing balloon in bladder neck, dilatation, and then slide U channel sheath device into bladder neck. And example is the ProACT device with information here:  https://www.proact-for-men.com/for-physicians

Two new codes were created for permanent fallopian tube occlusion:

• 0567T Permanent fallopian tube occlusion with degradable biopolymer implant, transcervical approach, including transvaginal ultrasound
• 0568T Introduction of mixture of saline and air for sonosalpingography to confirm occlusion of fallopian tubes, transcervical approach, including transvaginal ultrasound and pelvic ultrasound.

The polymer is temporary and eventually degrades.  Transcervical approach is accessing fallopian tubes through the cervix entrance.

Nervous System – Various New Codes and Updated Injection Codes

Spinal puncture codes were updated and added to denote diagnostic vs therapeutic spinal puncture and if with fluoro or CT guidance:

▲62270 Spinal puncture, lumbar, diagnostic;

• 62328 … with fluoroscopic or CT guidance

▲62272 Spinal puncture, therapeutic, for drainage of cerebrospinal fluid (by needle or catheter);

• 62329 … with fluoroscopic or CT guidance

Coders must not report 62328 and 62329 with 77003, 77012.  If ultrasound or MRI guidance is performed see 76942, 77021 instead of using the “with fluoro/CT” codes.   

Injection codes have been updated as follows:

▲64400 Injection(s), anesthetic agent(s) and/or steroid; trigeminal nerve, any division or branch each branch (ie, ophthalmic, maxillary, mandibular)

All codes in the family include the same editorial changes. The codes revised are 64405, 64408, 64416, 64417, 64418, 64425, 64430, 64435, 64446, 64448, 64449, and 64450

There are new introduction notes at the Somatic Nerves subsection to describe how and when these codes are reported. (i.e., how many injections, if imaging is included).  Somatic nerves are is the part of the peripheral nervous system associated with the voluntary control of body movements via skeletal muscles. The somatic nervous system consists of afferent nerves or sensory nerves, and efferent nerves or motor nerves. Other updates include adding “level” to show more specificity in the codes: 

▲64415 … brachial plexus, single

▲64420 … intercostal nerve, single level

+▲64421 … intercostal nerve, multiple, regional block, each additional level (List separately in addition to code for primary procedure)

▲64445 … sciatic nerve, single

▲64447… femoral nerve, single

64402 Injection, anesthetic agent; facial nerve

64410 Injection, anesthetic agent; phrenic nerve

64413 Injection, anesthetic agent; cervical plexus

Use 64999 for the facial, phrenic or cervical plexus

New codes were added for destruction, radiofrequency ablation and injection of agents into nerves of sacroiliac joint and genicular nerve:

• 64451 Injection(s), anesthetic agent(s) and/or steroid; nerves innervating the sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography)  (For bilateral procedure, use -50)
• 64454 Injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, including imaging guidance, when performed

Code 64454 REQUIRES injection of ALL THREE of these branches:  Superolateral, superomedial, inferomedial.  If not three, use 64454-52.

There is a new chart on page 437 of the CPT Professional book that outlines the different injections and if they include imaging guidance or not. 

• 64624 Destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed.  This is done for pain from osteoarthritis of the knee.

Code 64624 REQUIRES destruction of each of the following genicular nerve branches:  superolateral, superomedial, and inferomedial.  If neurolytic agent is not applied to ALL THREE, use 64634-52.

• 64625 Radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography)  For bilateral procedure use -50.   If with ultrasound, use 76999.  A photo here shows the three genicular nerves:  https://bmjopen.bmj.com/content/7/11/e016377

Radiofrequency ablation (RFA) is a procedure used to reduce pain. An electrical current produced by a radio wave is used to heat up a small area of nerve tissue, thereby decreasing pain signals from that specific area.

Five new Category III codes were added for posterior tibial nerve neurostimulation, sometimes abbreviated as PTNS.   PTNS is the least invasive form of neuromodulation used to treat overactive bladder and associated symptoms of urinary urgency, frequency, and incontinence.  A fine needle electrode is inserted into the lower inner leg and the goal is to send stimulation through the tibial nerve.   More information can be found here:  https://simonfoundation.org/ptns/

• 0587T Percutaneous Implantation OR replacement of integrated single device neurostimulation system including electrode array and received or pulse generator, including analysis, programming, and imaging guidance when performed, posterior tibial nerve
• 0588T REVISION OR REMOVAL of integrated single device neurostimulation system including electrode array and received or pulse generator, including analysis, programming, and imaging guidance when performed, posterior tibial nerve
• 0589T Electronic analysis with simple programming of implanted integrated neurostimulation system……  1-3 parameters
• 0590T Electronic analysis with simple programming of implanted integrated neurostimulation system…… 4 or more parameters

Ocular and Auditory Systems

New and revised codes were added as follows:

• 0563T  Evacuation of Meibomian Glands using heat delivered through wearable open-eye eyelid treatment devices and manual  gland expression, bilateral  (for manual evacuation of meibomian glands use E&M code)

▲66711 Ciliary body destruction; cyclophotocoagulation, endoscopic, without concomitant removal of crystalline lens

▲66982 Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (eg, iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage; without endoscopic cyclophotocoagulation

• 66987 … with endoscopic cyclophotocoagulation  (ECP)

▲66984 Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification); without  endoscopic cyclophotocoagulation

• 66988 … with endoscopic cyclophotocoagulation  (ECP)

ECP uses a laser endoscope containing three fiber groupings: an image guide, a light source, and the semiconductor diode laser. This technology allows direct visualization of the ciliary epithelium. This allows the laser energy to be precisely delivered to the ciliary processes, thus limiting damage to the underlying ciliary body and surrounding tissue.

• 0583T Tympanostomy (requiring insertion of ventilating tube) using an automated tube deliver system, iontophoresis local anesthesia.

The TULA System is a new technology for the placement of tympanostomy tubes in children with otitis media. The procedure is performed using local anesthesia in an outpatient setting.  Traditional tympanostomy tube placement is performed by surgeons in an operating room under general anesthesia, resulting in the substantial use of health care resources, patient and caregiver anxiety, and caregiver absence from work.  The TULA System (Acclarent, Inc., Menlo Park, California) is made up of two devices and coaching tools. The TULA IONTOPHORESIS SYSTEM is a headset equipped with single-use earplugs. Iontophoresis is a method to actively move charged drug molecules through the skin using low levels of electrical current. Ear electrodes within the earplugs connect to a control unit to deliver bilateral local anesthetic over ten minutes to the tympanic membrane. The TULA TubeDelivery System is used to make an incision in the tympanic membrane and insert a pre-loaded tympanostomy tube in a single automated motion. The entire procedure can be performed in an outpatient setting such as a clinic or doctor’s office. 

Our final Part 5 of the series will cover miscellaneous CPT updates not covered thus far such as  Evaluation and Management.

The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.