Get Ready: Your Cancer Treatment Code Options Will Grow As of Jan. 1, 2023
You’ve already looked at the new ICD-10-CM diagnosis codes and CPT 2023 procedure codes for oncology, and now it’s time to review the new Healthcare Common Procedure Coding System (HCPCS) Level II codes, which were recently released by The Centers for Medicare & Medicaid Services (CMS). Highlights for oncology include new codes for percutaneous breast biopsies, fulvestrant and bortezomib injections, and prolonged services.
Overall, these updates include 182 new and 101 revised codes. Also, 47 codes were deleted. Three new modifiers were added, and two modifiers were revised. These changes go into effect January 1, 2023.
What is HCPCS?
HCPCS codes are divided into Level I and Level II. Level I HCPCS codes include current procedural terminology (CPT®) codes, which the American Medical Association (AMA) maintains, according to cms.gov. Doctors and other healthcare professionals report the medical services and procedures they perform with CPT® codes.
On the other hand, Level II HCPCS codes are used to report products, supplies, and services that the CPT® code set does not include, per cms.gov. Examples include ambulance services, durable medical equipment, prosthetics, orthotics, and supplies (DEMPOS).
Discover Brand New HCPCS Level II Codes
CMS added several new HCPCS Level II codes regarding percutaneous breast biopsies. These codes include:
C7501 (Percutaneous breast biopsies using stereotactic guidance, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, all lesions unilateral and bilateral (for single lesion biopsy, use appropriate code)) and
C7502 (Percutaneous breast biopsies using magnetic resonance guidance …)).
You will also see new codes you can report for drugs used to treat certain types of breast cancer:
J9393 (Injection, fulvestrant (teva) not therapeutically equivalent to j9395, 25 mg) and
J9394 (Injection, fulvestrant (fresenius kabi) not therapeutically equivalent to j9395, 25 mg).
Additionally, you will gain three new codes to report multiple myeloma treatment, which include:
J9046 (Injection, bortezomib, (dr. reddy's), not therapeutically equivalent to j9041, 0.1 mg),
J9048 (Injection, bortezomib (fresenius kabi), not therapeutically equivalent to j9041, 0.1 mg), and
J9049 (Injection, bortezomib (hospira), not therapeutically equivalent to j9041, 0.1 mg).
Next, you will see one new code to report a drug used to prevent nausea and vomiting caused by chemotherapy: J1456 (Injection, fosaprepitant (teva), not therapeutically equivalent to j1453, 1 mg).
In 2023, CMS will also give you a new code, Q5126 (Injection, bevacizumab-maly, biosimilar, (alymsys), 10 mg), to report a drug used to treat different types of cancers, including metastatic colorectal cancer, non-small cell lung cancer, glioblastoma, and metastatic renal cell carcinoma.
Finally, you will see several new M-codes to report different types of care patients receive:
For example, submit M1156 if a patient received active chemotherapy during the measurement period.
Submit M1157 if the patient received a bone marrow transplant at any time during the measurement period.
Lastly, submit M1192 if the patient has an existing diagnosis of squamous cell carcinoma of the esophagus.
Documenting Time is Key for Prolonged Services Revisions
In CMS’ final rule, “they chose to adopt the 2021 evaluation and management (E/M) guidelines for leveling including hospital, observation, emergency room department, nursing facility, nursing home and other services requiring the three key elements in 2022,” said Kelly Loya, CPC, CHC, CRMA, CPhT, CHIAP, associate partner at Pinnacle Enterprise Risk Consulting Services. These changes are important to note, so that oncologists document their visits accurately and understand when their service does and does not qualify for a prolonged services add on code.
The descriptions have changed, indicating a medically appropriate history and exam, then leveling the medical decision-making component to support the level chosen. Also, the total time requirements have changed, Loya said. For example, 99221 (Initial hospital care, per day, for the evaluation and management of a patient…) currently requires 30 minutes of bedside or hospital floor time. However, in 2023, 99221 will require 40 minutes of “total time” to be met or exceeded. Total time will mean the total time spent on the patient on the calendar date of the visit.
When using the prolonged add-on codes, the AMA and CMS’ requirements differ. Therefore, like when adding G2212 (Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service; each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact …), since CMS requires a full 15 minutes beyond the total time for the highest-level outpatient E/M codes, CMS will similarly require the same for the new revised times for the highest level of the hospital inpatient, observation, nursing facility and home/residence E/M codes. Therefore, if you are seeing a patient insured by a private payer that follows AMA guidelines, only +55 minutes is required to use the prolonged add-on code 99217 with a 99215; however, if you are seeing a patient who has Medicare, CMS requires the use of G2212 when meeting or exceeding 69 minutes of total time. To reach these calculations, documenting the amount of time spent with a patient is critical.
Next year, you will be able to report the following new prolonged visit service add-on codes available, as follows:
G0316 (Prolonged hospital inpatient or observation care evaluation and management service(s) beyond the total time for the primary service (when the primary service has been selected using time on the date of the primary service; each additional 15 minutes …)
G0317 (Prolonged nursing facility evaluation and management service(s) beyond the total time for the primary service (when the primary service has been selected using time on the date of the primary service); each additional 15 minutes …)
G0318 (Prolonged home or residence evaluation and management service(s) beyond the total time for the primary service (when the primary service has been selected using time on the date of the primary service); each additional 15 minutes…)
In CMS’ final rule, they explain how these particular codes may be used, and it may not be what you think, Loya said. They explain when implementing these codes, the time at which your billing staff can submit the codes is only at the point where the physician documents exceeding the full valuation of the code time, which is another 15-minutes. Therefore, to report G0316 with 99223, which has a 75-minutes of total time requirement in 2023 according to the CPT® description, is when that 75 minutes is exceeded to 90 (meeting the full valuation of the 99223 CPT® code and another 15-minutes). In other words, the physician spent 90 minutes on the total time of the visit. So, the threshold for reporting 99223 and G0316 is 105 minutes.
If you are confused, you can refer to the category notes in the 2023 CPT® manual for more guidance, Loya added.
Check Out Revised Codes
CMS will also revise HCPCS Level II codes in 2023. For example, you will see changes to G9847 and G9848:
G9847 (Patient received
chemotherapysystemic cancer-directed therapy in the last 14 days of life). Emphasis added.G9848 (Patient did not receive
chemotherapysystemic cancer-directed therapy in the last 14 days of life). Emphasis added.
As you can see, “chemotherapy” has been removed from both of the above code descriptors, and “systemic cancer-directed therapy” will be used instead.
Some patient referral codes will also see revisions next year. For instance, G9968 (Patient was referred to another provider or specialist during the performance period) will change to (Patient was referred to another clinician or specialist during the measurement period).
Code G9969 will also see revisions: Clinician who referred the patient to another providerclinician received a report from the providerclinician to whom the patient was referred.
For both codes, the word “provider” will change to “clinician” in the descriptor.
Mark Down 2023 Deletions
You will also see several code deletions, meaning you won’t be able to report them in 2023. These deletions include the following:
G9250 (Documentation of patient pain brought to a comfortable level within 48 hours from initial assessment) and G9251 (Documentation of patient with pain not brought to a comfortable level within 48 hours from initial assessment)
G9618 (Documentation of screening for uterine malignancy or those that had an ultrasound and/or endometrial sampling of any kind) and G9620 (Patient not screened for uterine malignancy, or those that have not had an ultrasound and/or endometrial sampling of any kind, reason not given)
M1017 (Patient admitted to palliative care services).
