The CPT code set for 2024 has recently been released. The modifications discussed below pertain specifically to urology and will become effective on January 1, 2024, across all payers. While pricing and coverage details will be finalized for certain procedure codes, primarily for Medicare, with the release of the Medicare Physician Fee Schedule in late October or early November, we will keep you updated on these determinations and their anticipated impact on urology.
A notable portion of the new codes falls under the category of CPT Category III codes. These will necessitate additional investigation, particularly in terms of coverage and payment rates, especially when dealing with private payers. It’s crucial to bear in mind that CPT Category III codes are officially recognized as CPT codes and should be used to report services rendered, provided they most accurately describe the services offered, unless explicit instructions have been given by a payer (we strongly advise obtaining this in written form).
Traditionally, Medicare does not assign work relative value units (wRVUs) to CPT Category III codes. Nevertheless, it is becoming increasingly common for Medicare to include Category III services in its coverage. Some Medicare Administrative Contractors (MACs) may even publish local coverage articles. Furthermore, the Centers for Medicare & Medicaid Services (CMS) may categorize Category III codes for payment purposes in ambulatory surgical centers and hospital outpatient department payment classifications. This ensures specific reimbursements to facilities, even in the absence of established payment rates for physician services or coverage for the particular service, drug, or supply.
Evaluation and Management (E/M) Code Updates
The E/M section of CPT for 2024 has seen some administrative adjustments, although these changes are relatively minor when compared to the substantial revisions implemented in 2021 and 2023. There are two noteworthy alterations that we will discuss here.
Firstly, in a move towards greater consistency, CPT is revising how time is specified for Office and other Outpatient E/M codes. Currently, these codes include a time “range” as part of the description to guide code selection. In 2024, these codes will instead incorporate a time “threshold” to harmonize with other (non-Outpatient) E/M codes that utilize a time threshold. For example, the present descriptor for 99204 cpt code is “Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision-making.
When using time for code selection, 45 [to] 59 minutes of total time is spent on the date of the encounter.” In 2024, the description will be revised to state “Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision-making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded.” It’s important to note that this time threshold concept does not alter the existing time ranges, so E/M tools will not necessitate updating.
Secondly, CPT has introduced a definition for a Shared/Split visit. It appears that the American Medical Association aims to discourage CMS from proceeding with a proposal that would exclusively allow visits provided by a medical team consisting of an advanced practice provider (APP) and a physician to be reported based on the time spent by each provider. As outlined in the definition, Shared/Split visits should be determined by either time or the substantial portion of the medical decision-making process to ascertain whether the APP or the physician should report the service.
New Category I CPT Codes
cpt code 52284, which pertains to cystourethroscopy, involves mechanical urethral dilation and urethral therapeutic drug delivery through a drug-coated balloon catheter for urethral stricture or stenosis in males. This includes fluoroscopy if performed.
This new code, cpt code 52284, replaces the soon-to-be-deleted Category III code cpt 0499T, which also involves cystourethroscopy with mechanical dilation and urethral therapeutic drug delivery for urethral stricture or stenosis, including fluoroscopy if performed. The revised cpt code 52284 specifically covers the procedure of cystourethroscopy with mechanical urethral dilation of a urethral stricture, utilizing a specialized drug-coated balloon that provides therapeutic drug delivery to the urethra.
The proposed wRVU for this procedure is 3.10, and it has a 0-day global period. It’s important to note that code cpt 52284 is not an add-on code, and cpt codes 52000, cpt code 52281, cpt code 52283, cpt code 74450, and cpt code 76000 are already included and should not be reported separately. It’s crucial to avoid confusing code cpt 52284 with the similar-sounding CPT Category III code 0619T, which involves cystourethroscopy with transurethral anterior prostate commissurotomy and drug delivery, including transrectal ultrasound and fluoroscopy if performed. While both procedures use a balloon and deliver a drug, they differ in that they employ different balloons, surgical techniques, and target different organs (the prostate as opposed to the urethra). Therefore, it is imperative not to conflate these procedures or their respective instruments and indications.
Additionally, New Codes Have Been Introduced:
- cpt code 64596: This code covers the insertion or replacement of a percutaneous electrode array in the peripheral nerve, which includes an integrated neurostimulator. This code encompasses imaging guidance if performed and applies to the initial electrode array.
- +64597: This is an add-on code denoting each additional electrode array in the same procedure.
- cpt code 64598: This code is for the revision or removal of a neurostimulator electrode array in the peripheral nerve, which includes an integrated neurostimulator.
These new codes are designed to accommodate procedures involving peripheral nerve stimulators that incorporate an integrated stimulator (not a separate one). It’s worth noting that these codes are not applicable for procedures involving integrated devices on the sacral nerve, which will be reported using the new Category III codes 0786T-0790T for percutaneous implantation of a neurostimulator in the sacral region with an integrated neurostimulator. Similarly, if the tibial nerve is employed for bladder dysfunction, it should be reported using the new Category III codes 0816T-0819T, which will be described in greater detail below.
Lastly, cpt code 99459 covers a female pelvic exam and is listed separately in addition to the code for the primary procedure.
This is a practice expense-only code that captures the direct expenses associated with performing a female pelvic exam in a non-facility setting during a preventive medicine service (99381-99397) or an E/M service (99202-99215). As an add-on code, it should be reported only for the same date of service as the codes listed above.
Revised Category I CPT codes
The following codes contain revised descriptors, with changes in bold. These will be used for dates of service on or after January 1, 2024.
- 64590 (insertion or replacement of peripheral, sacral, or gastric neurostimulator pulse generator or receiver, requiring pocket creation and connection between electrode array and pulse generator or receiver)
- 64595 (revision or removal of peripheral, sacral, or gastric neurostimulator pulse generator or receiver, with detachable connection to electrode array)
CPT codes 64590 and 64595 are employed to document the insertion/replacement and revision/removal, respectively, of a sacral neurostimulator generator or receiver, which is linked to a separately positioned electrode array, either concurrently or as an independent procedure. For the year 2024, these codes have been modified to explicitly specify that they pertain to devices connected to a separately positioned array, substituting the term “direct or inductive coupling” with “connection between array and pulse generator and receiver.” Furthermore, the descriptors have been refined to clearly distinguish these codes from those utilized to report procedures involving integrated neurostimulator systems (where the generator or receiver comes with an attached or integral array implanted as a single unit).
This distinction arises due to the introduction of new codes for open integrated tibial nerve neurostimulator procedures, percutaneous integrated sacral neurostimulator system procedures, and percutaneous integrated peripheral nerve stimulator procedures. Additionally, these codes now have updated proposed RVU values, with 64590 valued at 5.10 wRVUs and 64595 valued at 3.79 wRVUs.
In the context of sacral nerve procedures, CPT code 64590 is employed alongside code 64561, which covers the percutaneous (trial or permanent) placement of the electrode array, either concurrently or as an independent procedure.
The revised parentheticals provide explicit guidance not to report code 64590 alongside code 64595 or in conjunction with the new Category I codes 64596, 64597, or 64598, which pertain to integrated peripheral nerve stimulation procedures.
New and revised Category III codes
Code 0587T: This code pertains to the percutaneous implantation or replacement of an integrated neurostimulation system for bladder dysfunction, which includes the electrode array and receiver or pulse generator. It encompasses the procedures of analysis, programming, and imaging guidance, if performed, specifically targeting the posterior tibial nerve.
Code 0588T: This code is applicable for the revision or removal of a percutaneously placed integrated neurostimulation system for bladder dysfunction. This includes the electrode array and receiver or pulse generator. The procedure involves analysis, programming, and imaging guidance, if performed, targeting the posterior tibial nerve.
Code 0589T: Involving electronic analysis with basic programming of an implanted integrated neurostimulation system for bladder dysfunction, including adjustments to contact groups, amplitude, pulse width, frequency (in Hertz), on/off cycling, burst patterns, dose lockout, patient-selectable settings, responsive neurostimulation, detection algorithms, closed-loop parameters, and passive settings. This is performed by a physician or other qualified healthcare professional and is specifically focused on the posterior tibial nerve, addressing 1 to 3 parameters.
Code 0590: This code encompasses electronic analysis with advanced programming, involving adjustments to 4 or more parameters of an implanted integrated neurostimulation system for bladder dysfunction.
Code 0816T: This code pertains to the open insertion or replacement of an integrated neurostimulation system for bladder dysfunction. It includes the placement of electrodes (such as an array or leadless option), as well as the pulse generator or receiver. The procedure also encompasses analysis, programming, and imaging guidance, if performed. This targets the posterior tibial nerve and can be performed subcutaneously.
Code 0817T: This code is used for procedures involving the subfascial placement of an integrated neurostimulation system for bladder dysfunction.
Code 0818T: This code is for the revision or removal of an integrated neurostimulation system for bladder dysfunction. The procedure includes analysis, programming, and imaging guidance, if performed, targeting the posterior tibial nerve. The approach for this procedure is subcutaneous.
Code 0819T: Similar to 0818T, this code is for procedures involving the subfascial placement of an integrated neurostimulation system for bladder dysfunction.
Advancements in neurostimulator technology are ongoing. Four new Category III codes have been introduced for reporting various procedures related to these devices, specifically for use on the tibial nerve in patients with bladder dysfunction. These procedures may involve the implantation of arrays or integrated devices, which combine a stimulator with an attached or internal array. These implantations can be performed through either open surgical methods (0816T-0819T) or percutaneous approaches (0587T and 0588T). The primary distinction between each CPT code lies in the surgical approach required to insert these devices. It is crucial to communicate clearly with your entire team regarding the approach used for each patient’s device implantation.
The programming of these devices on the day of the procedure is included in the codes. For electronic analysis with programming of an integrated or leadless neurostimulation system for bladder dysfunction, targeting the posterior tibial nerve, performed on a day following the device insertion, replacement, or revision, you should use codes 0589T and 0590T for simple (1-3 parameters) and complex (4 or more parameters) programming, respectively. Codes 0589T and 0590T should be reported for reprogramming of all posterior tibial devices, regardless of the insertion method, for days subsequent to the initial device implantation.
Subcutaneous Devices: Examples of subcutaneous devices include the eCoin device and Medtronic’s implantable tibial neuromodulation device. On the other hand, an example of a subfascial device is the Revi device. It’s important to note that these devices are placed through an open procedure, unlike devices that use a percutaneous approach targeting the tibial nerve, which are reported using the existing Category III codes (0587T, 0588T).
0786T (Insertion or Replacement of Percutaneous Electrode Array, Sacral, with Integrated Neurostimulator): This code is used for the percutaneous insertion or replacement of an electrode array integrated with a neurostimulator in the sacral region. The procedure includes imaging guidance, if performed.
0788T (Revision or Removal of Neurostimulator Electrode Array, Sacral, with Integrated Neurostimulator): This code is applicable for the revision or removal of a neurostimulator electrode array integrated with a neurostimulator in the sacral region.
0789T (Electronic Analysis with Simple Programming of Implanted Integrated Neurostimulation System): This code covers electronic analysis with basic programming of an implanted integrated neurostimulation system. It involves adjustments to various parameters, and the procedure is carried out by a physician or other qualified healthcare professional. This is performed on either the spinal cord or sacral nerve, addressing 1 to 3 parameters.
0790T (Electronic Analysis with Complex Programming): This code encompasses electronic analysis with advanced programming, involving adjustments to 4 or more parameters of an implanted integrated neurostimulation system.
Programming Codes (0789T and 0790T): Codes 0789T and 0790T are used to report programming of integrated neurostimulation systems. It’s important to note that these codes should not be reported on the same date as the insertion, but can be reported based on the number of parameters programmed on dates subsequent to the insertion.
0811T (Remote Multiday Complex Uroflowmetry): This code is for remote multiday complex uroflowmetry, which involves the use of calibrated electronic equipment. It also covers the setup and patient education on the use of the equipment.
0812T (Device Supply with Automated Report Generation): This code pertains to the supply of the device along with automated report generation, which is provided for up to 10 days.
Reporting 0812T: It’s important to note that code 0812T should not be reported more than once per episode of care. Additionally, these codes should not be reported in conjunction with certain other codes (51736, 51741, 99453, and 99454) related to remote patient monitoring.
0864T (Low-Intensity Extracorporeal Shock Wave Therapy): This code is used to report the performance of low-intensity extracorporeal shock wave therapy to the corpus cavernosum. This procedure is indicated in men with erectile dysfunction. It’s advised not to report code 0864T in conjunction with code 0101T when treating the same area.
The field of urology is witnessing a continuous influx of new drugs, biologicals, and devices. The introduction of these new codes serves the purpose of more accurately monitoring, encompassing, and reimbursing these novel treatments. The addition of fresh J codes and pass-through technology codes for facility reimbursement linked to these services adds a dynamic element to our practices. As emphasized before, it’s important to note that coverage and payment for cutting-edge technology are distinct from the incorporation of new codes.
Medicare now mandates every Medicare Administrative Contractor (MAC) to assess new technology, irrespective of the code type used for reporting associated procedures, as well as for newly introduced drugs and devices. In the past, Category III codes and unlisted codes were often associated with nonpayment. However, owing to Medicare’s new prerequisites and the rapid pace of technological advancement, Category III codes and unlisted codes are now routinely covered. Most practices have become adept at maneuvering the complexities surrounding reimbursement in this intricate system.
Private payers, on the other hand, adhere to their own set of regulations. While the Health Insurance Portability and Accountability Act requires all payers and medical groups to adopt new CPT codes once they are officially recognized, the process, coverage, and implementation of these new codes may vary among private payers. Ensuring up-to-date information from your payer has become notably more challenging as payers are increasingly difficult to reach.
Establishing fees for new codes lacking relative values should ideally be based on the proportional effort required compared to established services. This should also include sufficient compensation to cover the expenses associated with these novel devices and drugs. It is advisable to keep invoices readily available to substantiate incurred costs if necessary.
Lastly, the introduction of new devices, drugs, and techniques often necessitates the demonstration of medical necessity. We encourage you to invest time in examining each of these new service lines for their clinical effectiveness. Maintain documentation supporting patient selection criteria and comparative data—preferably sourced from peer-reviewed literature—either within the medical record or easily accessible to your prior authorization and billing team. It is essential for your group to have established and adhered to protocols backed by literature-supported data in order to secure payment and retain reimbursements for all services provided, particularly for these novel services.
We greatly appreciate the pioneering spirit of urology groups committed to advancing patient care. While not without its challenges, this endeavor can be highly rewarding for both your patients and your practice.
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