Medical coding can become really interesting if you know the way to deal with it. Surgical coding updates are here adding some more crisp to medical coding part in 2021. When American Medical Association released the new coding sets in January, 2021, it did not disappoint with changes and significance added to surgical coding updates.

Total coding changes that happened in 2021 are 329 which includes 206 additional codes, 54 deleted codes and 64 coding revisions. The below explains the coding updates according to divisions.

Evaluation and Management Services – The added codes are 2, the deleted code is 1, the revised codes are 17.

Anesthesia – The added codes are 0, the deleted codes are 0, and the revised codes are 0.

Surgery – The added codes are 11, the deleted codes are 11, and the revised codes are 28.

Radiology Procedures – The added codes are 2, the deleted codes are 2 and the revised codes are 6.

Pathology and Laboratory Procedures – The added codes are 43, deleted code is 1, the revised codes are 9.

Medicine Services and Procedures – The added codes are 18, deleted code is 1, the revised codes are 4.

Category II Codes – The added codes are 0, deleted codes are 0 and revised code is 1.

PLA Codes – The added codes are 85, deleted codes are 7 and the revised codes are 3.

Evaluation and Management coding updates:

  • There are several discussions happening among American Medical Association’s coding professionals about the necessity in changing or updating evaluation and management codes.
  • According to American Medical Association, the updated CPT codes including the office and E/M services have received more than expected in 25 years.
  • Evaluation and Management codes mainly for healthcare professionals’ office and outpatient services are separated into new and established services in order to note office codes and E/M codes.
  • Those guidelines include:
  1. The Code 99201 is deleted and code 99202 is used for parenthetical notes state.
  2. The Code descriptions changed for office or outpatient service E/M codes are 99202-99215.
  3. History and terminology is removed from evaluation and management coding office visits. It’s replaced with MDM- Medical Decision Making. Time is also assigned to CPT code descriptions.
  4. For office visits, evaluation and management state coders might choose appropriate level of E/M services using both medical decision making and time.
  5. New Medical Decision Making table is introduced to calculate the level of services. Important factors for office and outpatient visits include:
  • Number of issued addressed along with complexity in the problems.
  • Complexity and information to be reviewed.
  • Risk of complications and morbity of patient management.

Surgical Coding Updates 2021:

  • Integumentary system- Breast repair and reconstruction:

In surgical coding for integumentary system, there are 15 codes revised and 2 codes deleted. Those codes are 19324 and 19366. These codes are promptly used for breast repair and reconstruction subsection with codes 19316 and 19499.

Surgical coders are about to find new ways and instructional guidance for surgical coding and introductory guidelines. The updated surgical coding guidelines provide detailed information of the types of reconstruction used to repair defects using various techniques including latissimus dorsi flap, free flap and single or bipedicled transverse rectus abdominis myocutaneous.

  • Respiratory system- Nose:

New surgical coding with 30468 was added just to explain briefly or elaborate the repair of nasal valve collapse with subcutaneous or submucosal lateral wall implants.

This code was necessary to react and identify opening of nasal collapse through minimally invasive techniques and utilizing absorbable lateral wall implants.

Parenthetical guidance for code 30468 notes is to be used to report a bilateral procedure.

In case if the procedure is performed unilaterally, then add the modifiers 52.

  • Respiratory System- Lungs and Pleura:

The code 32408 is literally used in 2021 in order to report core needle biopsy of the lung or mediastinum. Unlimited and new guidelines 32408 clearly states not to report separately and the code is just used for lesion sampled with modifier 59.

  • Cardiovascular System- Cardiac Assist :

It has got two added CPT codes 33995 and 33997, four revised CPT codes 33990-33993 that reflects insertion, removal as well as repositioning right and left percutaneous ventricular assist devices.

These revised codes for left heart insertion and revision specify if only this procedure is performed through arterial access only with both arterial and venous access.

  • Male Genital System- Prostate:

A new code 55880 was added to report transrectal, high intensity-focused ultrasound (HIFU) guided ablation of malignant prostate tissue.

Earlier, coders were using an unlisted code to report this procedure.

  • Female Genital System- Cervix Uteri:

New code 57465 is created to report computer-aided colposcopy to aid in the biopsy of the cervix. In surgical coding, the code 57465 is only to be used in conjunction with vaginal colposcopy procedures 57420, 57421 and cervical colposcopy procedures 57452-57461.

  • Auditory System- Other Procedures:

New codes are introduced to create dilation of the eustachian tube using nasopharyngoscopy technique. This procedure is usually referred to as eustachian tube balloon dilation.

Earlier coders used unlisted code 69799 to report this procedure. Now the descriptions indicate that 69705 is for unilateral dilation and 69706 is for bilateral dilation.

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