CPT CORNER A look at new changes coming to E&M and breast coding in 2021 TABLE I: ELEMENT OF DECISION MAKING “CPT Corner” provides general information, TABLE I: ELEMENT OF DECISION MAKING with a minor problem pretty much meets that available at the time of publication, regarding #/COMPLEXITY AMOUNT/COMPLEXITY level just by entering the exam room. #/COMPLEXITY AMOUNT/COMPLEXITY RISK OF various coding, billing and claims issues of CODE(S) LEVEL OF MDM OF PROBLEMS OF DATA REVIEW/ RISK OF CMS is planning to update RVUs noted in CODE(S) LEVELLEVEL OFOF MDMMDM OF PROBLEMS OF DATA REVIEW/ COMPLICATIONS interest to plastic surgeons. ASPS is not respon- ADDRESSED ANALYZED COMPLICATIONS Table VI for E&M services when not included ADDRESSED ANALYZED sible for any action taken in reliance on the 99211 N/A N/A N/A N/A in the “global surgery” value of a code. Howev- information contained in this column. 99211 N/A N/A N/A N/A er, CMS has currently proposed to not make 99202 Minimal By Jeff Kozlow, MD, MS; Erika Adler; 99202 Straightforward Minimal Minimal Minimal the equivalent increase in valuation for those 99212 Straightforward (minor problem) Minimal Minimal & Catherine French 99212 (minor problem) visits that are bundled in the global period. 99203 Low 99203 Low Low Limited Low This incongruity is being actively addressed by 99213 Low (stable, uncomplicated) Limited Low he 2021 CPT Code set includes major 99213 (stable, uncomplicated) all surgical specialties, including ASPS. 99204 Moderate changes to evaluation and management 99204 Moderate Moderate Moderate Moderate 99214 Moderate (moderate problems) Moderate Moderate T (E&M) coding for office and outpatient 99214 (moderate problems) visits, as well as an overhaul to introductory 99205 High Breast coding 99205 High High Extensive High 99215 High (very ill) Extensive High guidelines and code descriptors for certain 99215 (very ill) Over the past 18 months, ASPS worked with breast procedures in an effort to clarify and the AMA CPT Panel as well as the RUC Panel streamline language. TABLE II: NUMBER/COMPLEXITY OF PROBLEMS TABLE II: NUMBER/COMPLEXITY OF PROBLEMS to clarify coding for breast reconstruction ser- In this month’s column, we will walk you RISK OF vices. Although the reporting of these codes CODE(S) LEVEL OF MDM RISK OF through the changes to ensure that you select CODE(S) LEVELLEVEL OFOF MDMMDM COMPLICATIONS was generally understood by our specialty, the most appropriate codes based on these up- COMPLICATIONS there was significant confusion from coders 99211 N/A N/A dates – which can help avoid audits and delayed 99211 N/A N/A and others leading to the specific request by 99202 reimbursement when coding your procedures 99202 Minimal (minor problem) • 1 self limited/minor problem the CPT Panel to provide better instructions 99212 Minimal (minor problem) • 1 self limited/minor problem in 2021. The basics of the new breast coding 99212 and descriptors for these codes, including instructions are presented in this issue, with a • 2 self limited/minor problems 99203 • 2 self limited/minor problems ones with ambiguous descriptors. 99203 Low (stable, uncomplicated) • 1 stable chronic illness more detailed look at many of the common 99213 Low (stable, uncomplicated) • 1 stable chronic illness Updates include using common lan- 99213 • 1 acute, uncomplicated illness or injury situations seen in breast reconstruction slated • 1 acute, uncomplicated illness or injury guage throughout the sections (e.g., the use for next month’s CPT Corner column. • 1 or more chronic illness with exacerbation/progres- • 1 or more chronic illness with exacerbation/progres-- of “breast implant” instead of “mammary sion or side effects 99204 sion or side effects implant”); updates to long descriptors and 99204 Moderate (moderate problems) • 2+ stable chronic disease 99214 Moderate (moderate problems) • 2+ stable chronic disease parentheticals; and the addition of 14 new 99214 • 1 acute illness with systematic symptoms E&M coding • 1 acute illness with systematic symptoms paragraphs to the introductory guidelines in • 1 acute complicated injury In 2019, CMS noted that guidelines for • 1 acute complicated injury the CPT book for the breast section. Some • 1+ chronic illness with severe exacerbation/profession/ E&M codes were outdated and a subsequent • 1+ chronic illness with severe exacerbation/profession/ of these codes went through the RUC survey 99205 side effects push began to simplify coding and documen- 99205 High (very ill) side effects process, as the changes were deemed more 99215 High (very ill) • 1 acute chronic illness or injury that poses a threat to 99215 • 1 acute chronic illness or injury that poses a threat to tation guidelines by reducing redundancies; life of bodily function than editorial, resulting in re-valuation. Al- eliminating the need to re-enter information lifelife ofof bodilybodily functionfunction though the valuation for many of these codes that had been previously recorded by ancillary is expected to change based on the RUC TABLE III: AMOUNT/COMPLEXITY OF DATA REVIEWED/ANALYZED staff; and to remove unnecessary history and TABLE III: AMOUNT/COMPLEXITY OF DATA REVIEWED/ANALYZED recommendations to CMS, those changes are AMOUNT/COMPLEXITY OF DATA exam elements. CODE(S) AMOUNT/COMPLEXITY OF DATA CRITERIA still in flux pending CMS release of the Final CODE(S) REVIEWED/ANALYZED CRITERIA Initially, CMS proposed a simplified code REVIEWED/ANALYZED Rule, which was not available at PSN press system based on what was to be considered 99211 N/A N/A time. However, it will be highlighted in next 99211 N/A N/A required documentation. The agency also month’s CPT Corner. 99202 proposed an elimination in pay differentials be- 99202 Minimal • Minimal or none Table VII presents the most basic changes 99212 Minimal • Minimal or none tween the previous levels of service. However, 99212 to each of the relevant code descriptors. The •Tests/Documents – Review of external notes from unique the AMA, along with various medical special- 99203 •Tests/Documents – Review of external notes from unique introductory language in the CPT book along 99203 Limited source, unique tests or ordering of unique tests (need 2) or ties, objected to the CMS proposal and instead 99213 Limited source, unique tests or ordering of unique tests (need 2) or with the additional parentheticals for some of 99213 • Assessment requiring an independent historian developed a new proposal that maintained the • Assessment requiring an independent historian the codes are too lengthy for print, but they • Tests/Documents – Review of external nodes from unique • Tests/Documents – Review of external nodes from unique current five levels of outpatient service – but source, unique test, ordering of unique test, independent can easily be found in the CPT book. How- source, unique test, ordering of unique test, independent still streamlined reporting requirements. historian (need 3) or ever, we have attempted to highlight the most historian (need 3) or The changes to the 2021 CPT Code set 99204 • Independent interpretation of a test performed by another significant changes. 99204 Moderate • Independent interpretation of a test performed by another for E&M services represent the first major 99214 Moderate physician/QHP or 99214 physician/QHP or • Discussion of management or test interpretation with external overhaul of office visit and outpatient E&M • Discussion of management or test interpretation with external CPT 11960 – Insertion of TE, Non-Breast MD/QHP coding in more than 25 years. These have MD/QHP Although this code is not breast related, it the potential to reduce payer audits, promote was included in this process at the request of • Tests/Documents – Review of external nodes from unique greater payer consistency and ensure payment • Tests/Documents – Review of external nodes from unique CPT due to proximity to 11970-71 and be- source, unique test, ordering of unique test, independent is “resource based,” and that no one specialty source, unique test, ordering of unique test, independent cause the most common diagnosis associated historian (need 3) or benefits more than others. historian (need 3) or with this code indicated inappropriate usage 99205 • Independent interpretation of a test performed by another 99205 Extensive • Independent interpretation of a test performed by another The most significant changes for CY 2021 99215 Extensive physician/QHP or in a balloon carpal tunnel procedure. After 99215 physician/QHP or involve how the level of service is determined • Discussion of management or test interpretation with external discussions with hand surgeons, a new paren- • Discussion of management or test interpretation with external – either by medical decision making (MDM) MD/QHP thetical was added that states 11960 should MD/QHP or time (total time spent with the patient, in- • NEED 2 of 3 for Level 5 • NEED 2 of 3 for Level 5 not be reported in conjunction with CPT cluding non-face-to-face services). Note that codes 11971, 13160, 29848 and 64702-26 have been changed a bit, and new guidelines Activities could include: medically appropriate history and/or exam- TABLE IV: AMOUNT/COMPLEXITY OF DATA REVIEWED to avoid this misusage. ination remains a documentation expectation and definitions have beenTABLE added IV: AMOUNT/COMPLEXITY for clarifi- • OFReviewing DATA REVIEWED tests cation. Most plasticAMOUNT/COMPLEXITY surgery visits OFwill DATA likely • Obtaining and reviewing any separately but will no longer be used in code selection. CODE(S) AMOUNT/COMPLEXITY OF DATA CRITERIA CPT 19325 – Breast Augmentation CODE(S) REVIEWED/ANALYZED CRITERIA You will also notice that 99201 has been have a low or moderateREVIEWED/ANALYZED level of complexity. obtained history The code descriptor for CPT 19325 has been deleted and there will no longer be a Level 1 The99211 amount of data will oftenN/A be limited or • Exam and/or counselingN/A and education updated to simplify and streamline language. moderate.99211 Still, the risks N/Aof complications • Ordering medications,N/A tests and procedures new patient visit. In addition, there were no 99202 A parenthetical has also been added to direct 99202 Minimal • Minimal or none changes to the outpatient consult codes or can 99212often be moderate orMinimal high, depending • Referring/communicating• Minimal or none with other users to use codes 15771 and 15772 when fat on the99212 type of care being provided. With the QHPs any of the inpatient E&M codes. Although •Tests/Documents – Review of external notes from unique grafting is performed in conjunction with a new99203 requirements, it will be very important •Tests/Documents• Documenting – Review information of external notes in from the unique EMR the acceptance of the outpatient consult codes 99203 Limited source, unique tests or ordering of unique tests (need 2) or breast augmentation with implant. 99213 Limited source, unique tests or ordering of unique tests (need 2) or (9924X) still varies based on insurer, report- to document99213 the specific elements required •• AssessmentIndependently requiring aninterpreting independent historiantest results It’s important to note that CPT 19324 for each of these sections to ensure accurate • Assessmentand communicating requiring an independent results historian ing of this code will still be based on current • Tests/Documents – Review of external nodes from unique – mammaplasty, augmentation without pros- reporting. In the tables displayed, remember • Tests/Documents – Review of external nodes from unique E&M guideline at this point. In addition, the source,If uniqueyou test,exceed ordering the of uniquetotal test,time, independent the new thetic implant – has been deleted. Fat grafting that the 9920X family of codes represents source, unique test, ordering of unique test, independent inpatient E&M codes will all still require the guidelines offerhistorian a way (need to receive3) or a bit more re- to the breast can now be reported with CPT historian (need 3) or previous levels of documentation, although new99204 patients; and the 9921X family of codes • Independent interpretation of a test performed by another codes 15771 and 15772. 99204 Moderate • Independentimbursement. interpretation New CPT of a test code performed 99417 by hasanother been represents99214 established patients.Moderate physician/QHP or this is the next targeted area for revision by 99214 crested to capturephysician/QHP each 15 or minutes of critical Alternatively, time may be used to select • Discussion of management or test interpretation with external the CPT Panel. • Discussionphysician/QHP of management work or test beyond interpretation time with spent external in CPT Codes 19316 & 19318 – Mastopexy MD/QHP Let’s take a deeper dive into the complexi- a code whether or not counseling or coordi- the office. This codeMD/QHP can only be used when & Reduction ties of medical decision-making for the revised nation of care dominated the service. Time the new/established code was selected based on No significant changes have been made to the includes physician and other qualified health • Tests/Documents – Review of external nodes from unique new and established outpatient E&M codes. • timeTests/Documents and can –only Review be of reported external nodes in conjunctionfrom unique descriptors of these two codes. CPT 19316 source, unique test, ordering of unique test, independent To qualify for a particular level of MDM, professional (QHP) time on the date of the source, unique test, ordering of unique test, independent remains unchanged, and in an effort to sim- with CPT codeshistorian 99205 (need and 3) or 99215. encounter and includes both face-to-face and historian (need 3) or two of the three elements for that specific 99205 • IndependentNote that interpretation to bill a of99202 a test performed using time, by another the pa - plify and streamline language throughout time99205 spent outside of theExtensive examination room. • Independent interpretation of a test performed by another level of MDM must be met or exceeded, 99215 Extensive tient would havephysician/QHP had to spend or 15-29 minutes the section, the descriptor for CPT 19318 Clinical99215 staff time (e.g., nurse or medical assis- physician/QHP or which is an unchanged concept from current • Discussionwith the of provider.management In or contrast,test interpretation to bill with a external99202 changed from “reduction mammoplasty” to • Discussion of management or test interpretation with external guidelines. However, the elements themselves tant) is not included for code selection. MD/QHP “breast reduction.” based on medicalMD/QHP decision-making, a patient • NEED 2 of 3 for Level 5 • NEED 2 of 3 for Level 5

TABLE V: RISKS OF COMPLICATIONS 10 TABLE V: RISKS OF COMPLICATIONS December 2020 CODE(S) RISK OF COMPLICATIONS CRITERIA CODE(S) RISK OF COMPLICATIONS CRITERIA 99211 N/A 99211 N/A 99202 99202 Minimal • Minimal risk of morbidity from additional testing or treatment 99212 Minimal • Minimal risk of morbidity from additional testing or treatment 99212 99203 99203 Low • Low risk of morbidity from additional testing or treatment 99213 Low • Low risk of morbidity from additional testing or treatment 99213 • Moderate risk of morbidity from additional diagnostic testing • Moderate risk of morbidity from additional diagnostic testing or treatment AMA Examples: or treatment AMA Examples: • Prescription drug management • Prescription drug management • Decision regarding minor surgery with identified patient or • Decision regarding minor surgery with identified patient or 99204 procedure risk factors 99204 Moderate procedure risk factors 99214 Moderate • Decision regarding elective major surgery without identified 99214 • Decision regarding elective major surgery without identified patient or procedure risk factors patient or procedure risk factors • Diagnosis or treatment significantly limited by social • Diagnosis or treatment significantly limited by social determinants of health determinants of health

• High risk of morbidity from additional diagnostic testing or • High risk of morbidity from additional diagnostic testing or treatment treatmenttreatment AMA Examples: AMAAMA Examples:Examples: 99205 • Decision regarding elective major surgery with identified 99205 Extensive • Decision regarding elective major surgery with identified 99215 Extensive patient or procedure risk factors 99215 patient or procedure risk factors • Decision regarding emergency major surgery • Decision regarding emergency major surgery • Decision regarding hospitalization • Decision regarding hospitalization

TABLE VI: REPORTING BASED ON TIME TABLE VI: REPORTING BASED ON TIME CODE(S) 2020 TYPICAL TIME CURRENT RVU 2021 TYPICAL TIME 2021 RVU CODE(S) 2020 TYPICAL TIME CURRENT RVU 2021 TYPICAL TIME 2021 RVU New Patients New Patients 99201 10 minutes 0.48 Deleted N/A 99201 10 minutes 0.48 Deleted N/A 99202 20 minutes 0.93 15-29 minutes 0.93 99202 20 minutes 0.93 15-29 minutes 0.93 99203 30 minutes 1.42 30-44 minutes 1.60 99203 30 minutes 1.42 30-44 minutes 1.60 99204 45 minutes 2.43 45-59 minutes 2.60 99204 45 minutes 2.43 45-59 minutes 2.60 99205 60 minutes 3.17 60-74 minutes 3.50 99205 60 minutes 3.17 60-74 minutes 3.50 Established Patients Established Patients 99211 5 minutes 0.18 N/A 0.18 99211 5 minutes 0.18 N/A 0.18 99212 10 minutes 0.48 10-19 minutes 0.70 99212 10 minutes 0.48 10-19 minutes 0.70 99213 15 minutes 0.97 20-29 minutes 1.30 99213 15 minutes 0.97 20-29 minutes 1.30 99214 25 minutes 1.50 30-29 minutes 1.92 99214 25 minutes 1.50 30-29 minutes 1.92 99215 40 minutes 2.11 40-54 minutes 2.80 99215 40 minutes 2.11 40-54 minutes 2.80 Prolonged Services Add-On Code Prolonged Services Add-On Code 99417 +15 minutes N/A +15 minutes 0.61 99417 +15 minutes N/A +15 minutes 0.61

TABLE VII: 2021 CHANGE TO BREAST CODES TABLE VII: 2021 CHANGE TO BREAST CODES CPT CODE 2020 DESCRIPTORS 2021 DESCRIPTOR CPT CODE 2020 DESCRIPTORS 2021 DESCRIPTOR Insertion of tissue expander(s) for other than Insertion of tissue expander(s) for other than breast, 11960 InsertionInsertion ofof tissuetissue expander(s)expander(s) forfor otherother thanthan InsertionInsertion ofof tissuetissue expander(s)expander(s) forfor otherother thanthan breast,breast, 11960 breast, including subsequent expansion including subsequent expansion breast, including subsequent expansion includingincluding subsequentsubsequent expansionexpansion Insertion of tissue expander(s) for other than Replacement of tissue expander with permanent 11970 InsertionInsertion ofof tissuetissue expander(s)expander(s) forfor otherother thanthan Replacement of tissue expander with permanent 11970 breast, including subsequent expansion implant breast, including subsequent expansion implantimplant Removal of tissue expander(s) without insertion Removal of tissue expander without insertion of 11971 Removal of tissue expander(s) without insertion Removal of tissue expander without insertion of 11971 of prosthesis permanent implant of prosthesis permanent implant 19316 Mastopexy Mastopexy (no change) 19316 Mastopexy Mastopexy (no change) 19318 Reduction mammaplasty Breast reduction 19318 Reduction mammaplasty Breast reduction Mammaplasty, augmentation; without prosthetic 19324 Mammaplasty, augmentation; without prosthetic CODE HAS BEEN DELETED 19324 implant CODE HAS BEEN DELETED implantimplant Mammaplasty, augmentation; with prosthetic 19325 Mammaplasty, augmentation; with prosthetic Breast augmentation with implant 19325 implant Breast augmentation with implant implantimplant 19328 Removal of intact mammary implant Removal of intact breast implant 19328 Removal of intact mammary implant Removal of intact breast implant Removal of ruptured breast implant, including implant 19330 Removal of mammary implant material Removal of ruptured breast implant, including implant 19330 Removal of mammary implant material contents (eg, saline, silicone, gel) contents (eg, saline, silicone, gel) Immediate insertion of breast prosthesis follow- Insertion of breast implant on same day of mastectomy 19340 ImmediateImmediate insertioninsertion ofof breastbreast prosthesisprosthesis followfollow-- InsertionInsertion ofof breastbreast implantimplant onon samesame dayday ofof mastectomymastectomy 19340 ing mastopexy, mastectomy or in reconstruction (ie, immediate) inging mastopexy,mastopexy, mastectomymastectomy oror inin reconstructionreconstruction (ie, immediate) Delayed insertion of breast prosthesis following Insertion or replacement of breast implant on separate 19342 Delayed insertion of breast prosthesis following InsertionInsertion oror replacementreplacement ofof breastbreast implantimplant onon separateseparate 19342 mastopexy, mastectomy or in reconstruction day from mastectomy mastopexy, mastectomy or in reconstruction day from mastectomy Breast reconstruction, immediate or delayed, Breast reconstruction, immediate or delayed, Tissue expander placement in breast reconstruction, 19357 with tissue expander, including subsequent Tissue expander placement in breast reconstruction, 19357 with tissue expander, including subsequent including subsequent expansion(s) expansion includingincluding subsequentsubsequent expansion(s)expansion(s) expansion Breast reconstruction with latissimus dorsi 19361 Breast reconstruction with latissimus dorsi Breast reconstruction; with latissimus dorsi flap 19361 flap, without prosthetic implant Breast reconstruction; with latissimus dorsi flap flap, without prosthetic implant Breast reconstruction; with free flap 19364 Breast reconstruction with free flap Breast reconstruction; with free flap 19364 Breast reconstruction with free flap (e.g. fTRAM, DIEP, SIEA, GAP flap) (e.g.(e.g. fTRAM,fTRAM, DIEP,DIEP, SIEA,SIEA, GAPGAP flap)flap) Breast reconstruction with transverse rectus Breast reconstruction with transverse rectus ab- Breast reconstruction with transverse rectus Breast reconstruction with transverse rectus ab- 19367 abdominis myocutaneous flap (TRAM), single dominis myocutaneous flap (TRAM), single pedicle, 19367 abdominis myocutaneous flap (TRAM), single dominis myocutaneous flap (TRAM), single pedicle, pedicle, including closure of donor site; including closure of donor site; pedicle, including closure of donor site; includingincluding closureclosure ofof donordonor site;site; Breast reconstruction with transverse rectus Breast reconstruction with single-pedicled transverse Breast reconstruction with transverse rectus Breast reconstruction with single-pedicled transverse abdominis myocutaneous flap (TRAM), single rectus abdominis myocutaneous (TRAM) flap, 19368 abdominis myocutaneous flap (TRAM), single rectusrectus abdominisabdominis myocutaneousmyocutaneous (TRAM)(TRAM) flap,flap, 19368 pedicle, including closure of donor site; with requiring separate microvascular anastomosis pedicle, including closure of donor site; with requiringrequiring separateseparate microvascularmicrovascular anastomosisanastomosis microvascular anastomosis (supercharging) (supercharging) microvascular anastomosis (supercharging) (supercharging)(supercharging) Breast reconstruction with transverse rectus Breast reconstruction with transverse rectus Breast reconstruction with bipedicled transverse 19369 abdominis myocutaneous flap (TRAM), double Breast reconstruction with bipedicled transverse 19369 abdominis myocutaneous flap (TRAM), double rectus abdominis myocutaneous (TRAM) flap pedicle, including closure of donor site rectusrectus abdominisabdominis myocutaneousmyocutaneous (TRAM)(TRAM) flapflap pedicle, including closure of donor site 19366 Breast reconstruction with other technique CODE HAS BEEN DELETED 19366 Breast reconstruction with other technique CODE HAS BEEN DELETED Revision of peri-implant capsule, breast, including Revision of peri-implant capsule, breast, including 19370 Open periprosthetic capsulotomy, breast capsulotomy, capsulorrhaphy, and/or partial capsu- 19370 Open periprosthetic capsulotomy, breast capsulotomy, capsulorrhaphy, and/or partial capsu- lectomy lectomylectomy Peri-implant capsulectomy, breast, complete, includ- 19371 Periprosthetic capsulectomy, breast Peri-implant capsulectomy, breast, complete, includ- 19371 Periprosthetic capsulectomy, breast ing removal of all intra-capsular contents inging removalremoval ofof allall intra-capsularintra-capsular contentscontents Revision of reconstructed breast (eg, significant Revision of reconstructed breast (eg, significant removal of tissue, re-advancement and/or re-inset removalremoval ofof tissue,tissue, re-advancementre-advancement and/orand/or re-insetre-inset 19380 Revision of reconstructed breast of flaps in autologous reconstruction or significant 19380 Revision of reconstructed breast of flaps in autologous reconstruction or significant capsular revision combined with soft tissue excision capsular revision combined with soft tissue excision in implant-based reconstruction.) inin implant-basedimplant-based reconstruction.)reconstruction.) 19350 Nipple/areola reconstruction Nipple/areola reconstruction (no change) 19350 Nipple/areola reconstruction Nipple/areola reconstruction (no change) TABLE I: ELEMENT OF DECISION MAKING #/COMPLEXITY AMOUNT/COMPLEXITY RISK OF CODE(S) LEVEL OF MDM OF PROBLEMS OF DATA REVIEW/ COMPLICATIONS ADDRESSED ANALYZED 99211 N/A N/A N/A N/A 99202 Minimal Straightforward Minimal Minimal 99212 (minor problem) 99203 Low Low Limited Low 99213 (stable, uncomplicated) 99204 Moderate Moderate Moderate Moderate 99214 (moderate problems) 99205 High High Extensive High 99215 (very ill)

TABLE II: NUMBER/COMPLEXITY OF PROBLEMS RISK OF CODE(S) LEVEL OF MDM COMPLICATIONS 99211 N/A N/A 99202 Minimal (minor problem) • 1 self limited/minor problem 99212 TABLE I: ELEMENT OF DECISION MAKING TABLE I: ELEMENT OF DECISION MAKING • 2 self limited/minor problems #/COMPLEXITY AMOUNT/COMPLEXITY 99203 #/COMPLEXITY AMOUNT/COMPLEXITY RISK OF Low (stable, uncomplicated) • 1 stable chronic illnessRISK OF CODE(S) LEVEL OF MDM OF PROBLEMS OF DATA REVIEW/ CODE(S)99213 LEVEL OF MDM OF PROBLEMS OF DATA REVIEW/ COMPLICATIONS • 1 acute, uncomplicated illnessCOMPLICATIONS or injury ADDRESSED ANALYZED ADDRESSED ANALYZED • 1 or more chronic illness with exacerbation/progres- 99211 N/A N/A N/A N/A 99211 N/A N/A N/A sion or side effects N/A 99204 99202 Minimal 99202 Moderate (moderate problems)Minimal • 2+ stable chronic disease Straightforward Minimal Minimal 99214 Straightforward Minimal Minimal 99212 (minor problem) 99212 (minor problem) • 1 acute illness with systematic symptoms • 1 acute complicated injury 99203 Low 99203 Low Low Limited Low Low Limited Low 99213 (stable, uncomplicated) 99213 (stable, uncomplicated) • 1+ chronic illness with severe exacerbation/profession/ 99205 side effects 99204 Moderate 99204 High (very ill)Moderate Moderate Moderate Moderate 99215 Moderate • 1 acuteModerate chronic illness or injury that posesModerate a threat to 99214 (moderate problems) 99214 (moderate problems) life of bodily function 99205 High 99205 High High Extensive High High Extensive High 99215 (very ill) 99215 TABLE III: AMOUNT/COMPLEXITY(very ill) OF DATA REVIEWED/ANALYZED AMOUNT/COMPLEXITY OF DATA TABLE II: NUMBER/COMPLEXITY OF PROBLEMS CODE(S) TABLE II: NUMBER/COMPLEXITY OF PROBLEMSCRITERIA REVIEWED/ANALYZED RISK OF RISK OF CODE(S) LEVEL OF MDM CODE(S)99211 LEVELN/A OF MDM N/A COMPLICATIONS COMPLICATIONS 99202 99211 MinimalN/A • Minimal orN/A none 99211 N/A N/A 99212 99202 99202 Minimal (minor problem) •Tests/Documents• –1 Reviewself limited/minor of external problemnotes from unique Minimal (minor problem) • 1 self limited/minor problem 9920399212 99212 Limited source, unique tests or ordering of unique tests (need 2) or 99213 • Assessment• 2requiring self limited/minor an independent problems historian • 2 self limited/minor problems 99203 99203 Low (stable, uncomplicated) • 1 stable chronic illness Low (stable, uncomplicated) • 1 stable chronic illness 99213 • Tests/Documents – Review of external nodes from unique 99213 • 1 acute, uncomplicated illness or injury • 1 acute, uncomplicated illness or injury source, unique test, ordering of unique test, independent • 1 or more chronic illness with exacerbation/progres- • 1 or more chronichistorian illness (need with 3) orexacerbation/progres- TABLE I: ELEMENT OF DECISION MAKING sion or side effects 99204 • Independent interpretationsion orof sidea test effects performed by another 99204 99204 Moderate Moderate (moderate#/COMPLEXITY problems) AMOUNT/COMPLEXITY• 2+ stable chronic disease 99214 Moderate (moderate problems) • physician/QHP2+ stable chronic or disease 99214 RISK OF 99214 CODE(S) LEVEL OF MDM OF PROBLEMS OF •DATA 1 acute REVIEW/ illness with systematic symptoms • Discussion of• 1management acute illness orwith test systematic interpretation symptoms with external COMPLICATIONS ADDRESSED ANALYZED• 1 acute complicated injury • 1 acuteMD/QHP complicated injury 99211 N/A N/A • 1+ chronicN/A illness with severe exacerbation/profession/N/A • 1+ chronic illness with severe exacerbation/profession/ 99205 side effects 99205 • Tests/Documents – Reviewside of externaleffects nodes from unique 99202 High (very ill) Minimal High (very ill) 99215 Straightforward • 1 acute Minimalchronic illness or injury that posesMinimal a threat to 99215 source,• 1 uniqueacute chronic test, ordering illness orof injuryunique that test, poses independent a threat to 99212 (minor problem) life of bodily function historianlife of (needbodily 3)function or 99205 • Independent interpretation of a test performed by another 99203 Low Extensive Low Limited Low 99215 physician/QHP or 99213 TABLE III: AMOUNT/COMPLEXITY(stable, uncomplicated) OF DATA REVIEWED/ANALYZED TABLE III: AMOUNT/COMPLEXITY OF DATA REVIEWED/ANALYZED • Discussion of management or test interpretation with external 99204 Moderate AMOUNT/COMPLEXITYModerate OF DATA Moderate Moderate AMOUNT/COMPLEXITY OF DATA MD/QHP CODE(S)99214 (moderate problems) CRITERIA CODE(S) CRITERIA REVIEWED/ANALYZED REVIEWED/ANALYZED • NEED 2 of 3 for Level 5 99205 High 99211 High N/A Extensive N/A High 99211 N/A N/A 99215 (very ill) 99202 TABLE IV: AMOUNT/COMPLEXITY OF DATA REVIEWED 99202 Minimal • Minimal or none Minimal • Minimal or none 99212 99212 TABLE II: NUMBER/COMPLEXITY OF PROBLEMS AMOUNT/COMPLEXITY OF DATA CODE(S) CRITERIA •Tests/Documents – Review of external notes from unique REVIEWED/ANALYZED •Tests/Documents – Review of external notes from unique 99203 RISK OF 99203 CODE(S) LEVELLimited OF MDM source, unique tests or ordering of unique tests (need 2) or Limited source, unique tests or ordering of unique tests (need 2) or 99213 COMPLICATIONS 9921399211 N/A N/A • Assessment requiring an independent historian • Assessment requiring an independent historian 99202 99211 N/A N/A Minimal • Tests/Documents – •Review Minimal of orexternal none nodes from unique • Tests/Documents – Review of external nodes from unique 99212 99202 source, unique test, ordering of unique test, independent source, unique test, ordering of unique test, independent Minimal (minor problem) • 1 self limited/minor problem •Tests/Documents – Review of external notes from unique 99212 historian (need 3) or 99203 historian (need 3) or 99204 • Independent interpretation of a test performed by another 99204 Limited •source, Independent unique interpretationtests or ordering of a of test unique performed tests (need by another 2) or Moderate • 2 self limited/minor problems 99213 Moderate 9921499203 physician/QHP or 99214 • Assessment requiringphysician/QHP an independent or historian Low (stable, uncomplicated) • 1 stable chronic illness 99213 • Discussion of management or test interpretation with external • Discussion of management or test interpretation with external • 1 acute, uncomplicated illness or injury • Tests/Documents – Review of external nodes from unique MD/QHP source, unique test, orderingMD/QHP of unique test, independent • 1 or more chronic illness with exacerbation/progres- historian (need 3) or sion or side effects 99204 • Tests/Documents – Review of external nodes from unique 99204 • IndependentTests/Documents interpretation – Review of aexternal test performed nodes from by anotherunique Moderate (moderate problems) • 2+ stable chronic disease Moderate 99214 source, unique test, ordering of unique test, independent 99214 source, unique test, physician/QHPordering of unique or test, independent • 1 acute illness with systematic symptoms historian (need 3) or • Discussion of managementhistorian or (need test interpretation3) or with external • 1 acute complicated injury 99205 • Independent interpretation of a test performed by another 99205 • Independent interpretationMD/QHP of a test performed by another Extensive Extensive 99215 • 1+ chronic illnessphysician/QHP with severe or exacerbation/profession/ 99215 physician/QHP or 99205 • Discussion of management orside test effects interpretation with external • Discussion of management or test interpretation with external High (very ill) • Tests/Documents – Review of external nodes from unique 99215 • 1 acute chronic illnessMD/QHP or injury that poses a threat to source, unique test, orderingMD/QHP of unique test, independent • NEEDlife 2 of of bodily 3 for Level function 5 • NEEDhistorian 2 of (need 3 for 3)Level or 5 99205 • Independent interpretation of a test performed by another Extensive TABLE III: AMOUNT/COMPLEXITY OF DATA REVIEWED/ANALYZED 99215 physician/QHP or TABLE IV: AMOUNT/COMPLEXITY OF DATA REVIEWED TABLE IV: AMOUNT/COMPLEXITY OF DATA REVIEWED • Discussion of management or test interpretation with external AMOUNT/COMPLEXITY OF DATA CODE(S) AMOUNT/COMPLEXITY OF DATA CRITERIA AMOUNT/COMPLEXITY OF DATA MD/QHP CODE(S) REVIEWED/ANALYZED CRITERIA CODE(S) CRITERIA REVIEWED/ANALYZED REVIEWED/ANALYZED • NEED 2 of 3 for Level 5 99211 N/A N/A 99211 N/A N/A 99211 N/A N/A 99202 TABLE V: RISKS OF COMPLICATIONS 99202 Minimal • Minimal or none 99202 99212 Minimal • Minimal or none Minimal • Minimal or none 99212 CODE(S)99212 RISK OF COMPLICATIONS CRITERIA •Tests/Documents – Review of external notes from unique 99203 •Tests/Documents – Review of external notes from unique 99211 N/A •Tests/Documents – Review of external notes from unique 99203 Limited source, unique tests or ordering of unique tests (need 2) or 99203 99213 Limited source, unique tests or ordering of unique tests (need 2) or Limited source, unique tests or ordering of unique tests (need 2) or 99213 • Assessment requiring an independent historian 9920299213 • Assessment requiring an independent historian Minimal • Minimal• Assessment risk of morbidity requiring from an additional independent testing historian or treatment 99212 • Tests/Documents – Review of external nodes from unique • Tests/Documents – Review of external nodes from unique • Tests/Documents – Review of external nodes from unique source, unique test, ordering of unique test, independent 99203 source, unique test, ordering of unique test, independent Low •source, Low risk unique of morbidity test, ordering from additional of unique testing test, independent or treatment historian (need 3) or 99213 historian (need 3) or historian (need 3) or 99204 • Independent interpretation of a test performed by another 99204 Moderate • Independent interpretation of a test performed by another 99204 • •Moderate Independent risk ofinterpretation morbidity from of a additionaltest performed diagnostic by another testing 99214 Moderate physician/QHP or Moderate 99214 physician/QHP or 99214 or treatmentphysician/QHP AMA Examples: or • Discussion of management or test interpretation with external • Discussion of management or test interpretation with external • Discussion of •management Prescription drugor test management interpretation with external MD/QHP MD/QHP • Decision regarding minorMD/QHP surgery with identified patient or 99204 procedure risk factors Moderate • Tests/Documents – Review of external nodes from unique 99214 • Decision regarding elective major surgery without identified • Tests/Documents – Review of external nodes from unique • Tests/Documents – Review of external nodes from unique source, unique test, ordering of unique test, independent patient or procedure risk factors source, unique test, ordering of unique test, independent source, unique test, ordering of unique test, independent historian (need 3) or • Diagnosis or treatment significantly limited by social historian (need 3) or historian (need 3) or 99205 • Independent interpretation of a test performed by another determinants of health 99205 Extensive • Independent interpretation of a test performed by another 99205 • Independent interpretation of a test performed by another 99215 Extensive physician/QHP or Extensive 99215 physician/QHP or 99215 physician/QHP or • Discussion of management or test interpretation with external • Discussion of management or test interpretation with external • Discussion• High risk of morbiditymanagement from or additional test interpretation diagnostic with testing external or MD/QHP MD/QHP treatmentMD/QHP • NEED 2 of 3 for Level 5 • NEED 2 of 3 for Level 5 • NEED AMA 2 of Examples: 3 for Level 5 99205 • Decision regarding elective major surgery with identified Extensive 99215 patient or procedure risk factors TABLE IV:TABLE AMOUNT/COMPLEXITY V: RISKS OF COMPLICATIONS OF DATA REVIEWED TABLE V: RISKS OF COMPLICATIONS • Decision regarding emergency major surgery AMOUNT/COMPLEXITY OF DATA CODE(S) RISK OF COMPLICATIONS • Decision regardingCRITERIA hospitalization CODE(S)CODE(S) RISK OF COMPLICATIONS CRITERIACRITERIA REVIEWED/ANALYZED 99211 N/A 99211 N/A 99211 N/A N/A 99202 99202 Minimal • Minimal risk of morbidity from additional testing or treatment 99202 Minimal • Minimal risk of morbidity from additional testing or treatment 99212 TABLE VI: REPORTING BASED ON TIME 99212 Minimal • Minimal or none 99212 CODE(S)99203 2020 TYPICAL TIME CURRENT RVU 2021 TYPICAL TIME 2021 RVU 99203 Low • Low risk of morbidity from additional testing or treatment Low ••Tests/Documents Low risk of morbidity – Review from additionalof external testing notes fromor treatment unique 99213 9921399203 New Patients Limited source, unique tests or ordering of unique tests (need 2) or 99213 • Moderate risk of morbidity from additional diagnostic testing • Moderate• Assessment risk of morbidity requiring from an independentadditional diagnostic historian testing 99201 10 minutes 0.48 Deleted N/A or treatment AMA Examples: or treatment AMA Examples: • Tests/Documents• Prescription – Review drug of external management nodes from unique 99202 20 minutes 0.93 •15-29 Prescription minutes drug management 0.93 • Decisionsource, unique regarding test, minor ordering surgery of unique with identified test, independent patient or 99203 30 minutes 1.42 • Decision regarding30-44 minutesminor surgery with identified1.60 patient or historian (need 3) or 99204 procedure risk factors 99204 procedure risk factors Moderate 99204 Moderate • Independent interpretation of a test performed by another 9920499214 45 minutes 2.43 • Decision regarding45-59 minuteselective major surgery without2.60 identified 99214 Moderate • Decision regarding elective major surgery without identified 99214 patient physician/QHPor procedure risk or factors 99205 60 minutes 3.17 60-74patient minutes or procedure risk factors 3.50 • Discussion• Diagnosis of management or treatment orsignificantly test interpretation limited withby social external • Diagnosis or treatment significantly limited by social Established Patients determinantsMD/QHP of health determinants of health 99211 5 minutes 0.18 N/A 0.18 •• HighTests/Documents risk of morbidity – Review from additionalof external diagnostic nodes from testing unique or 99212 10 minutes 0.48 • High risk of morbidity10-19 minutes from additional diagnostic0.70 testing or source, unique test, orderingtreatment of unique test, independent treatment 99213 15 minutes 0.97 20-29 minutes 1.30 historian AMA Examples:(need 3) or AMA Examples: 99205 • Independent interpretation of a test performed by another 9920599214 25 minutes 1.50 • Decision regarding30-29 minutes elective major surgery with1.92 identified 99205 Extensive • Decision regarding elective major surgery with identified Extensive 99215 Extensive physician/QHP or 99215 patient or procedure risk factors 99215 patient or procedure risk factors 99215 40 minutes 2.11 40-54 minutes 2.80 • Discussion• Decision of management regarding emergencyor test interpretation major surgery with external • Decision regarding emergency major surgery • Decision regardingMD/QHP hospitalization Prolonged Services Add-On •Code Decision regarding hospitalization • NEED 2 of 3 for Level 5 99417 +15 minutes N/A +15 minutes 0.61

TABLETABLE VI: V: REPORTING RISKS OF COMPLICATIONS BASED ON TIME TABLETABLE VII: VI: 2021 REPORTING CHANGE BASEDTO BREAST ON TIME CODES CODE(S)CODE(S) 2020 RISKTYPICAL OF COMPLICATIONS TIME CURRENT RVU 2021 TYPICALCRITERIA TIME 2021 RVU CPTCODE(S) CODE 2020 TYPICAL2020 TIME DESCRIPTORSCURRENT RVU 2021 TYPICAL2021 TIME DESCRIPTOR2021 RVU 99211 N/A New Patients Insertion of tissue expander(s) for otherNew than Patients Insertion of tissue expander(s) for other than breast, 11960 99202 breast, including subsequent expansion including subsequent expansion 99201 10 minutesMinimal 0.48 • Minimal risk of morbidityDeleted from additional testingN/A or treatment 99201 10 minutes 0.48 Deleted N/A 99212 Replacement of tissue expander with permanent Replacement of tissue expander with permanent 99202 20 minutes 0.93 15-29 minutes 0.93 9920211970 20 minutes 0.93 15-29 minutes 0.93 99203 prosthesis implant 99203 30 minutes Low 1.42 • Low risk of 30-44morbidity minutes from additional testing 1.60or treatment 99203 30 minutes 1.42 30-44 minutes 1.60 99213 Removal of tissue expander(s) without insertion Removal of tissue expander without insertion of 11971 99204 45 minutes 2.43 • Moderate risk45-59 of morbidity minutes from additional diagnostic2.60 testing 99204 45 minutes of prosthesis 2.43 45-59 minutespermanent implant 2.60 99205 60 minutes 3.17 60-74or treatment minutes AMA Examples: 3.50 9920519316 60 minutes Mastopexy 3.17 60-74 minutesMastopexy (no change) 3.50 • Prescription drug management Established• PatientsDecision regarding minor surgery with identified patient or 19318 Reduction mammaplastyEstablished Patients Breast reduction 99204 procedure risk factors 99211 5 minutes 0.18 N/A 0.18 99211 5 minutesModerate 0.18 N/A 0.18 Mammaplasty, augmentation; without prosthetic 99214 • Decision regarding elective major surgery without identified 19324 CODE HAS BEEN DELETED 99212 10 minutes implant 0.48 10-19 minutes 0.70 99212 10 minutes 0.48 10-19patient minutes or procedure risk factors 0.70 Mammaplasty, augmentation; with prosthetic 99213 15 minutes 0.97 • Diagnosis20-29 or treatment minutes significantly limited1.30 by social 9921319325 15 minutes 0.97 20-29Breast minutes augmentation with implant1.30 determinants of health implant 99214 25 minutes 1.50 30-29 minutes 1.92 99214 25 minutes 1.50 30-29 minutes 1.92 19328 Removal of intact mammary implant Removal of intact breast implant 99215 40 minutes 2.11 40-54 minutes 2.80 99215 40 minutes 2.11 40-54 minutes 2.80 • High risk of morbidity from additional diagnostic testing or Removal of ruptured breast implant, including implant 19330 Removal of mammary implant material Prolonged Services Add-On Code treatment Prolonged Services Add-On Codecontents (eg, saline, silicone, gel) AMA Examples: 99417 +15 minutes N/A +15 minutes 0.61 99417 Immediate+15 minutes insertion of breast prosthesisN/A follow- Insertion+15 of breast minutes implant on same day of0.61 mastectomy 99205 • Decision regarding elective major surgery with identified 19340 Extensive ing mastopexy, mastectomy or in reconstruction (ie, immediate) CPT99215 Codes 19340 & 19342 – Implant the removalpatient of orthe procedure expander; risk factors minor revisions TABLE VII: 2021 CHANGE TO •BREAST Decision CODESregarding emergency major surgery Delayed insertion TABLEof breast VII: prosthesis 2021 CHANGEfollowing TOInsertion BREAST or CODES replacement of breast implant on separate Placement in Breast Reconstruction to the capsule; and placement of the new 19342 • Decision regarding hospitalization mastopexy, mastectomy or in reconstruction day from mastectomy DescriptorsCPT CODE of these codes2020 have DESCRIPTORS changed slight- breast implant. Note2021 DESCRIPTOR that CPT 19370 may be CPT CODE 2020 DESCRIPTORS 2021 DESCRIPTOR Breast reconstruction, immediate or delayed, ly to again simplifyInsertion and of tissue streamline expander(s) language. for other than reportedInsertion if ofmore-extensive tissue expander(s) forcapsular other than revisions breast, Insertion of tissue expander(s) for other than TissueInsertion expander of tissue placement expander(s) in breastfor other reconstruction, than breast, 11960 1935711960 with tissue expander, including subsequent The term “breast breast,implant” including is now subsequent used expansioninstead are performed.including Do subsequentnot report expansion CPT 11971 in breast, including subsequent expansion includingincluding subsequent subsequent expansion(s) expansion TABLE VI: REPORTING BASED ON TIME expansion of “breast prothesis.”Insertion ofThe tissue codes expander(s) are usedfor other for than conjunctionReplacement with of tissue11970 expander. with permanent Insertion of tissue expander(s) for other than Replacement of tissue expander with permanent 11970 11970 Breast reconstruction with latissimus dorsi placementCODE(S) of a2020 newbreast, TYPICAL implant including TIME or subsequent replacementCURRENT expansion in RVU 2021 TYPICAL TIMEimplant 2021 RVU 19361 breast, including subsequent expansion Breast reconstruction;implant with latissimus dorsi flap flap, without prosthetic implant mastectomy orRemoval reconstructed of tissue expander(s) breast. withoutNew insertion PatientsCPT 19370Removal of– tissueRevision expander of without Breast insertion Capsule of Removal of tissue expander(s) without insertion Removal of tissue expander without insertion of 11971 11971 Breast reconstruction; with free flap The code selection dependsof prosthesis on the tradi- The biggest changepermanent for CPT implant 19370 is that it’s 19364 Breast reconstructionof prosthesis with free flap permanent implant tional99201 definitions 10of minutes immediate vs. delayed0.48 no longer usedDeleted just for capsulotomiesN/A but for (e.g. fTRAM, DIEP, SIEA, GAP flap) 19316 Mastopexy Mastopexy (no change) 19316 Mastopexy Mastopexy (no change) reconstruction,99202 and20 onminutes the relationship to0.93 the revisions 15-29of peri-implantminutes capsule0.93 including Breast reconstruction with transverse rectus Breast reconstruction with transverse rectus ab- 19318 Reduction mammaplasty Breast reduction timing9920319318 of the mastectomy.30 minutesReduction Valuation mammaplasty for these1.42 capsulotomy,30-44 minutescapsulorraphyBreast reduction and/or1.60 partial 19367 abdominis myocutaneous flap (TRAM), single dominis myocutaneous flap (TRAM), single pedicle, two codes is Mammaplasty,expected to augmentation; be the same. without Note prosthetic capsulectomy. CPT 19342 can be separately Mammaplasty,pedicle, including augmentation; closure withoutof donor prosthetic site; including closure of donor site; 1932499204 45 minutes 2.43 45-59CODE minutes HAS BEEN DELETED2.60 19324 CODE HAS BEEN DELETED that a new parenthetical has implantbeen added that reported when placing a new implant. CPT Breast reconstructionimplant with transverse rectus Breast reconstruction with single-pedicled transverse 99205 60 minutes 3.17 60-74 minutes 3.50 states 19342 andMammaplasty, 19328 should augmentation; not be with report prosthetic- 19370 can be reported with tissue expander abdominisMammaplasty, myocutaneous augmentation; flap with (TRAM), prosthetic single rectus abdominis myocutaneous (TRAM) flap, 19325 Breast augmentation with implant 1936819325 Breast augmentation with implant ed in conjunction for removalimplant of implantEstablished in Patientsexchange if significant capsular work is per- pedicle, including closureimplant of donor site; with requiring separate microvascular anastomosis microvascular anastomosis (supercharging) (supercharging) the 19328same99211 breast. ForRemoval5 minutesremoval of intact of mammarytissue expand implant0.18 - formed. NoteRemovalN/A that of you intact cannot breast implant report0.18 19370 19328 Removal of intact mammary implant Removal of intact breast implant er and placement with a breast implant, use in conjunction with CPT 19328 for removal Breast reconstruction with transverse rectus 99212 10 minutes 0.48 10-19 minutes 0.70 RemovalBreast ofreconstruction ruptured breast with implant, bipedicled including transverse implant Removal of ruptured breast implant, including implant 1936919330 abdominisRemoval myocutaneous of mammary flapimplant (TRAM), material double CPT19330 code 11970Removal. of mammary implant material and replacement of the same implant to access rectus contentsabdominis (eg, myocutaneous saline, silicone, (TRAM) gel) flap Codes99213 19340 15and minutes 19342 can both0.97 be the capsule.20-29contents minutes (eg, saline, silicone, gel)1.30 pedicle, including closure of donor site Immediate insertion of breast prosthesis follow- Insertion of breast implant on same day of mastectomy Immediate insertion of breast prosthesis follow- Insertion of breast implant on same day of mastectomy separately1934099214 reportable25 minutes with a flap, including1.50 30-29 minutes 1.92 1936619340 Breast reconstruction with other technique CODE HAS BEEN DELETED ing mastopexy, mastectomy or in reconstruction (ie, immediate) ing mastopexy, mastectomy or in reconstruction (ie, immediate) latissimus99215 dorsi flap.40 minutes Acellular dermal matrix2.11 CPT 1937140-54 – minutes Complete Capsulectomy2.80 Revision of peri-implant capsule, breast, including Delayed insertion of breast prosthesis following Insertion or replacement of breast implant on separate Delayed insertion of breast prosthesis following Insertion or replacement of breast implant on separate (ADM)19342 is separately reportable as well using The descriptor for CPT 19371 has been 1937019342 Open periprosthetic capsulotomy, breast capsulotomy, capsulorrhaphy, and/or partial capsu- CPT 15777. mastopexy, mastectomy Prolongedor in reconstruction Servicesupdated Add-On Code to becomeday from more mastectomy descriptive of the mastopexy, mastectomy or in reconstruction day fromlectomy mastectomy 99417 Breast+15 reconstruction, minutes immediate orN/A delayed, procedure.+15 CPT minutes 19371 is for 0.61a complete Breast reconstruction, immediate or delayed, Tissue expander placement in breast reconstruction, TissuePeri-implant expander capsulectomy, placement breast,in breast complete, reconstruction, includ- 19357 with tissue expander, including subsequent 1935719371 withPeriprosthetic tissue expander, capsulectomy, including subsequent breast CPT 19357 – Placement of TE in Breast capsulectomyincluding and subsequent includes expansion(s)the removal of all ing includingremoval ofsubsequent all intra-capsular expansion(s) contents expansionTABLE VII: 2021 CHANGE TO BREAST CODES expansion Reconstruction intra-capsular contents. It cannot be reported Revision of reconstructed breast (eg, significant CPT 19357 Breastis used reconstruction for tissue with latissimusexpander dorsi with CPT 19328 and 19370; however, 19342 Breast reconstruction with latissimus dorsi CPT19361 CODE 2020 DESCRIPTORS Breast reconstruction;2021 DESCRIPTOR with latissimus dorsi flap 19361 removalBreast reconstruction;of tissue, re-advancement with latissimus and/or dorsi re-inset flap placement in breastflap, reconstruction; without prosthetic includes implant can be separately reported for replacement of 19380 Revisionflap, without of reconstructed prosthetic implant breast of flaps in autologous reconstruction or significant Insertion of tissue expander(s) for other than Insertion of tissue expander(s) for other than breast, subsequent11960 expansion(s); and is separately re- a new implant.Breast reconstruction; with free flap capsularBreast revision reconstruction; combined with with soft free tissue flap excision 19364 breast,Breast including reconstruction subsequent with freeexpansion flap including subsequent expansion 19364 Breast reconstruction with free flap portable if used in flap reconstruction. There’s (e.g. fTRAM, DIEP, SIEA, GAP flap) (e.g.in implant-based fTRAM, DIEP, reconstruction.)SIEA, GAP flap) Insertion of tissue expander(s) for other than Replacement of tissue expander with permanent now11970 clear language that the placement of a CPT 19380 – Revision of Reconstructed 19350 Breast reconstructionNipple/areola withreconstruction transverse rectus BreastNipple/areola reconstruction reconstruction with transverse (no change) rectus ab- Breastbreast, reconstruction including subsequent with transverse expansion rectus Breast reconstructionimplant with transverse rectus ab- TE 19367is separatelyabdominis reported myocutaneous with a lat flap dorsi (TRAM), flap single Breast dominis myocutaneous flap (TRAM), single pedicle, 19367 abdominis myocutaneous flap (TRAM), single dominis myocutaneous flap (TRAM), single pedicle, Removal of tissue expander(s) without insertion Removal of tissue expander without insertion of or contour irregularities (CPT 15771, 15772), is the word “prosthesis” for “permanent im- (1936111971). This willpedicle, allow including for closuremore of accurate donor site; CPT 19380including is used closure when of donora revision site; is made pedicle, including closure of donor site; including closure of donor site; of prosthesis permanent implant may be separately reportable. plant.” Use CPT 11971 for removal of a tis- reporting, comparedBreast reconstruction to when 19340 with transverse was used rectus to Breastan reconstructionalready reconstructed with single-pedicled breast transverse that Breast reconstruction with transverse rectus Breast reconstruction with single-pedicled transverse for the19316 tissue abdominisexpander, myocutaneous andMastopexy will flap reflect (TRAM), the single includes rectus significant abdominisMastopexy myocutaneousremoval (no change) of (TRAM) tissue; flap, re-ad - 19380 shouldabdominis not be myocutaneous reported inflap conjunc (TRAM), -singlesue expanderrectus abdominis without myocutaneous insertion of(TRAM) an implant. flap, 19368 tion19368 with the following codes; 12031, 12032, Note that this code can be used for both breast additional19318 postoperativepedicle, includingReduction work. closure mammaplasty of donor site; with vancementrequiring and/or separateBreast re-inset microvascular reduction of flapsanastomosis in autol - pedicle, including closure of donor site; with requiring separate microvascular anastomosis microvascular anastomosis (supercharging) ogous reconstruction;(supercharging) or significant capsular 12033, 12034, microvascular12305, 12306, anastomosis 12307, (supercharging) 13100, and non-breast usage.(supercharging) CPT 11971 and 11970 Mammaplasty, augmentation; without prosthetic CPT19324 11970 –Breast TE to reconstruction Implant Exchangewith transverse rectus revisions combinedCODE HAS with BEEN soft-tissueDELETED excision 13101, 13102,Breast 15877, reconstruction 19316, 19318, with transverse 19370 rectus, should not be reported together. For removal implant Breast reconstruction with bipedicled transverse Breast reconstruction with bipedicled transverse CPT19369 11970 abdominishas had myocutaneousa slight change flap (TRAM), in de -doublein implant-based reconstruction. for the19369 same breast.abdominis myocutaneous flap (TRAM), doubleof a breast tissue expander and replacement Mammaplasty, augmentation; with prosthetic rectus abdominis myocutaneous (TRAM) flap rectus abdominis myocutaneous (TRAM) flap scriptor,19325 changingpedicle, the including word closure“prosthesis” of donor siteto The exchangesBreast augmentation for a new with or implant different size, pedicle, including closure of donor site with a breast implant, use 11970. implant “implant”19366 to simplifyBreast reconstruction and streamline with other language technique shape or typeCODE of HASimplant BEEN DELETED(CPT 19342), or CPT19366 11971 – RemovalBreast reconstruction of a Tissue with Expanderother technique CODE HAS BEEN DELETED throughout19328 the section.Removal ofThis intact mammarycode includes implant autologous Removalfat-grafting of intact for breast increased implant volume The only change in the descriptor for 11971 Continued on page 33 Revision of peri-implant capsule, breast, including Revision of peri-implant capsule, breast, including Removal of ruptured breast implant, including implant 1937019330 OpenRemoval periprosthetic of mammary capsulotomy, implant material breast capsulotomy, capsulorrhaphy, and/or partial capsu- 19370 Open periprosthetic capsulotomy, breast capsulotomy, capsulorrhaphy, and/or partial capsu- contents (eg,lectomy saline, silicone, gel) lectomy December 2020 11 Immediate insertion of breast prosthesis follow- InsertionPeri-implant of breast capsulectomy, implant on breast, same daycomplete, of mastectomy includ- Peri-implant capsulectomy, breast, complete, includ- 1937119340 Periprosthetic capsulectomy, breast 19371 Periprosthetic capsulectomy, breast ing mastopexy, mastectomy or in reconstruction ing removal of(ie, all immediate) intra-capsular contents ing removal of all intra-capsular contents Delayed insertion of breast prosthesis following Insertion or replacement of breast implant on separate 19342 Revision of reconstructed breast (eg, significant Revision of reconstructed breast (eg, significant mastopexy, mastectomy or in reconstruction removal of tissue,day re-advancementfrom mastectomy and/or re-inset removal of tissue, re-advancement and/or re-inset 19380 BreastRevision reconstruction, of reconstructed immediate breast or delayed, of flaps in autologous reconstruction or significant 19380 Revision of reconstructed breast of flaps in autologous reconstruction or significant Tissue expander placement in breast reconstruction, 19357 with tissue expander, including subsequent capsular revision combined with soft tissue excision capsular revision combined with soft tissue excision including subsequent expansion(s) expansion in implant-based reconstruction.) in implant-based reconstruction.) 19350 Breast Nipple/areolareconstruction reconstruction with latissimus dorsi Nipple/areola reconstruction (no change) 19350 Nipple/areola reconstruction Nipple/areola reconstruction (no change) 19361 Breast reconstruction; with latissimus dorsi flap flap, without prosthetic implant Breast reconstruction; with free flap 19364 Breast reconstruction with free flap (e.g. fTRAM, DIEP, SIEA, GAP flap) Breast reconstruction with transverse rectus Breast reconstruction with transverse rectus ab- 19367 abdominis myocutaneous flap (TRAM), single dominis myocutaneous flap (TRAM), single pedicle, pedicle, including closure of donor site; including closure of donor site; Breast reconstruction with transverse rectus Breast reconstruction with single-pedicled transverse abdominis myocutaneous flap (TRAM), single rectus abdominis myocutaneous (TRAM) flap, 19368 pedicle, including closure of donor site; with requiring separate microvascular anastomosis microvascular anastomosis (supercharging) (supercharging) Breast reconstruction with transverse rectus Breast reconstruction with bipedicled transverse 19369 abdominis myocutaneous flap (TRAM), double rectus abdominis myocutaneous (TRAM) flap pedicle, including closure of donor site 19366 Breast reconstruction with other technique CODE HAS BEEN DELETED Revision of peri-implant capsule, breast, including 19370 Open periprosthetic capsulotomy, breast capsulotomy, capsulorrhaphy, and/or partial capsu- lectomy Peri-implant capsulectomy, breast, complete, includ- 19371 Periprosthetic capsulectomy, breast ing removal of all intra-capsular contents Revision of reconstructed breast (eg, significant removal of tissue, re-advancement and/or re-inset 19380 Revision of reconstructed breast of flaps in autologous reconstruction or significant capsular revision combined with soft tissue excision in implant-based reconstruction.) 19350 Nipple/areola reconstruction Nipple/areola reconstruction (no change) CPT Corner from mastectomy, use CPT 19342. Insertion or breast reduction (19318), depending on Continued from page 10 of a tissue expander with a latissimus dorsi the technique used. Editor’s Message flap should be reported using CPT 19357. Continued from page 6 CPT 19328 – Removal of Intact Breast This code was not part of the group of CPT 19350 – Nipple Reconstruction Implant codes that were recently surveyed, and we do No significant changes have been made to the ship. It is fulfilling to me; but that’s not the Again, in an effort to streamline and simplify not expect any changes to the value. descriptor for 19350 and this code was not only place where I find my fit. Sometimes language, the only change made to the de- part of the group of codes that were recently it’s the O.R., the lab, occasionally a wine scriptor for CPT 19328 is changing the word CPT 19364 – Free Flap Breast Recon- surveyed. However, we wanted to note that a bar, sometimes with a group of other par- “mammary” to “breast.” Use this code for struction new parenthetical has been added under this ents at the park, but usually at home with removal of an intact breast implant. The short descriptor for CPT 19364 now code that states 19350 should not be reported my husband introducing our daughter to This code is not reported when an implant formally includes DIEPs and other flaps such in conjunction with CPT codes 11920, 11921, classic movies. That led to the Yoda Chia is being replaced with another implant and is as TRAM, SIEA and GAP. CPT and CMS 11922, 14001, 15100, 15200 and 15201. Pet she ordered this spring, which unfortu- included in the code for complete capsulecto- had previous established years ago that all nately was “lost” in the move. My husband my (CPT 19371). breast free flaps should be reported with this and I love exploring a city. Although get- code but required it to now be formally listed. Medicare conversion factor ting to know Chicago and my new part- CPT 19330 – Removal of a Ruptured As before, this code includes the flap harvest; Physicians should be aware of the proposed ners has been limited by social restrictions, Breast Implant microsurgical anastomosis of one artery and decrease in the conversion factor for 2021 I have found connection by being present. The major update for CPT 19330 is that two veins with use of an operating microscope – from $36.0896 to $32.2605. Under the Like everything else during the pan- it now includes both the implant and the (not separately reportable); flap inset as a proposed Medicare Physician Fee Schedule, demic, establishing – much less maintain- implant contents such as saline, silicone or breast mound; and donor site closure. CMS is proposing an almost 11 percent ing – a connection is more challenging than gel. This code is not separately reported with This code was not part of the group of decrease in payment. This reduction mostly ever. I am a firm believer in multitasking. a complete capsulectomy if all contents are codes that were recently surveyed, and we do stems from adjustments that are being made I would write grants during conferences, intracapsular; however, the placement of a not expect any changes to the value. to accommodate new spending resulting from edit or review manuscripts on conference new implant during the same operative ses- implementation of the changes to the E&M calls and sign charts between clinic visits. sion (CPT 19342) can be separately reported. CPT 19367, 19368, 19369 – Pedicled payments in the budget neutral system. I got a lot done, but I was never fully en- Remember that this is for removal of the im- TRAM techniques ASPS submitted comments to CMS re- gaged. Making a connection requires that plant and implant contents if ruptured, and There have been no significant changes made garding the Society’s concerns that because of you be present in the moment. That may should not be reported for the removal of a to the descriptors of these codes, and they budget neutrality requirements, the proposed be the only obligation. ruptured tissue expander. If a tissue expander were not part of the group of codes that were decrease and its negative redistributive effect on My last Editor’s Message in the June has ruptured and is being replaced with a recently surveyed; therefore, we do not expect some – but not all – physicians increases strain issue of PSN closed with hope and admi- breast implant, use CPT 11970. For removal any change to their values. on physicians and practices already feeling ration and, thankfully, that has not been of a ruptured tissue expander without replace- Note that these codes include harvesting of the negative impacts due to the public health lost – even with everything that has trans- ment, use CPT 11971. the flap, closure of the donor site, and insetting emergency. ASPS has been working closely pired in my life in the months in between. and shaping of the flap. with Surgical Care Coalition and other physi- I am moved by the resilience of my friends, CPT 19361 – Latissimus Dorsi Flap cian groups to address the significant change partners and family during this time. We Updates for 19361 include clarification on CPT 19366 – Other Technique that will occur. Additionally, we continue to really are taking care of each other. As it reporting and implant and/or tissue expander CPT 19366 has been deleted due to ambi- advocate our concerns directly to Congress re- would happen, I found my own connec- at the same time as a flap. For insertion of a guity in the descriptor. Partial breast recon- garding the negative impact a decrease in reim- tion and resilience over these months, and breast implant with latissimus dorsi flap on struction and oncoplastic procedures should bursement during a public health emergency I am forever grateful. the same day as a mastectomy, report CPT be reported with the Adjacent Tissue Transfer will have on patient care. Ideally, a “fix” will Now hopefully my sense of smell code 19340. For insertion of a breast implant (ATT) family of codes (14000, 14001, occur before Jan. 1, and ASPS will continue to makes its way back. Be well, stay safe. PSN with latissimus dorsi flap on a day separate 14301, and/or 14302), mastopexy (19316) share updates as they become known. PSN

BEFORE & AFTER PHOTOS

Build trust with your brand on PlasticSurgery.org and get more patients with ASPS. ASK A SURGEON Millions visit the ASPS website to get informed,

be prepared and find a great surgeon—like you! VIDEO CONTENT Your practice microsite is visible throughout PlasticSurgery.org, so potential patients are introduced to you, not just your practice information. The Plastic Surgeon Connect™ premium profile generates five times the consultation requests through the ASPS referral service and patient community.

Set up your profile today and be the answer patients FIND A SURGEON are looking for.

PlasticSurgery.org/Connect

December 2020 33