On November 1, 2024, the Centers for Medicare & Medicaid Services (CMS) released the final rules for calendar year (CY) 2025 Hospital Outpatient Prospective Payment System (HOPPS).1 For HOPPS, the main highlight is the proposed increase in payments for CY 2025 and adjustments related to hospital extensions and waivers from the public health emergency (PHE) ending. HOPPS Payment Rates CMS used the CY 2023 claims data for rate setting for CY 2025, which follows the usual 2-year difference in data for rate setting due to allowance for 1 year of timely filing for billing.
CMS finalized a 2.9% increase to the outpatient department (OPD) fee schedule. Based on the market update from the Inpatient Prospective Payment System (IPPS) of 3.4% and a 0.5% productivity adjustment decrease, this results in a final conversion factor (CF) of $89.169 for hospitals that meet the Hospital Outpatient Quality Reporting (OQR) requirements; applying the 2% reduction to those that do not, the CF is $87.439. CMS estimates total payments to HOPPS providers will be approximately $87.7 billion, an increase of approximately $4.7 billion compared to CY 2024 HOPPS payments.

Cancer Hospital Payment

Adjustment For CY 2025, CMS will continue the additional payments to cancer hospitals utilizing a payment-to-cost ratio (PCR) factor. Beginning in CY 2018, the 21st Century Cures Act required the weighted average PCR to be reduced by 1 percentage point. CMS finalized the target PCR of 0.87 to determine the CY 2025 cancer hospital payment adjustment to be paid at cost report settlement, which includes the 1% reduction; this is a decrease from recent year adjustment factors.

Procedures Assigned to New Technology APC Groups

When new technology is assigned a billing code, the establishment of a payment rate by CMS can be difficult because there are no claims data to determine utilization and cost by the hospital. Due to this factor, CMS created New Technology Ambulatory Payment Classifications (APCs), which are similar to pass-through payments for new drugs, biologicals, radiopharmaceuticals, and devices. The new technology is assigned to a temporary APC until claims data are available. Typically, this is for a minimum of 2 years but could be less if there are sufficient data available sooner. Once there are sufficient data, the new technology is moved to a clinically appropriate APC.

Biology-Guided Radiation Therapy

This technology uses positron-emitting radiopharmaceuticals to control delivery of radiation therapy to treat primary and metastatic lung or bone tumors.

For CY 2025, CMS is finalizing its proposal to base payment rates on CY 2023 claims data. HCPCS codes C9794 and C9795 became effective January 1, 2024, so there are no claims data for those services. CMS is finalizing and will continue to assign HCPCS code C9794 to APC 1521 (New Technology—Level 21 [$1901-$2000]) with a payment rate of $1,950.50 and HCPCS code C9795 to APC 1525 (New Technology—Level 25 [$3501-$4000]) with a payment rate of $3,750.50 (Table 1). CMS noted that effective January 1, 2025, 2 new G-codes are replacing HCPCS codes C9794 and C9795, G0562 and G0563, respectively. These new G-codes have the same code descriptors as C9794 and C9795 and were established to allow for payment in other settings besides hospital outpatient departments for CY 2025. HCPCS simulation code G0562 will have professional and technical components under the Medicare Physician Fee schedule (MPFS) similar to the other simulation codes, CPT® 77280-77290. Additionally, both G0562 and G0563 have set rates by Medicare as part of the New Technology APCs, but under MPFS, these codes will be contractor priced for CY 2025.

Proposed HOPPS Payment Status and Comment Indicators

Payment status indicators (SIs) are assigned to codes and APCs to help determine payment for HOPPS services. Specifically, SIs identify if a code is payable under HOPPS or another payment system and if HOPPS policies apply to the code.

For CY 2025 and subsequent years, CMS finalized its proposal to create 2 new SIs, K1 and H1, to identify drugs and other biologicals that qualify for separate payment under the new policy for nonopioid postsurgical pain management drugs, biologicals, and devices. The finalized SIs with their definitions and payment status are listed in Table 2.

CMS also finalized its proposal to modify the definition of SI K to remove the word therapeutic from the phrase “therapeutic radiopharmaceuticals to identify both diagnostic and therapeutic radiopharmaceuticals may be assigned to K.” The finalized descriptor reads: “Non-passthrough Drugs and Non-implantable Biologicals, Including Radiopharmaceuticals."

Payments of Drugs, Biologicals (including Biosimilar Products), and Radiopharmaceuticals

Each year CMS assesses payments for drugs and biologicals based on current pricing methodologies, which includes payments for drugs and biologicals considered separately payable based on the assigned APC or pass-through status. For CY 2025, CMS will continue the current payment policy in effect from CY 2013. Additionally, CMS indicated that the agency does not believe it must continue to propose the longstanding payment policies year after year. Instead, only if there is a change to a policy regarding payment for drugs, biologicals (including biosimilars), and radiopharmaceuticals will the proposed policy be outlined. The items in which CMS is proposing new policy or payment include:

• CMS finalized its proposal to package drugs and biologicals estimated at a per-day administration cost less than or equal to $140. In CY 2024, this threshold was set at less than or equal to $135. CMS did finalize to exclude diagnostic radiopharmaceuticals from this list and establish a different threshold.
• CMS will continue to except biosimilars from the threshold packaging policy when their reference biologicals are separately paid. If a reference product’s per-day cost falls below the threshold packaging policy, CMS has finalized all the biosimilars related to the reference product would be similarly packaged regardless of whether their per-day costs are above the threshold.

Payment for Diagnostic Radiopharmaceuticals

Historically, diagnostic radiopharmaceuticals have been packaged into the imaging they are performed with and not paid separately. CMS has done this for multiple reasons, primarily because it believes packaging policies are an inherent principle of HOPPS. However, CMS also feels strongly about ensuring the availability of new and innovative diagnostic services for
beneficiaries.

For the CY 2024 proposed rule, CMS sought comments from stakeholders regarding payment for diagnostic radiopharmaceuticals. The agency was looking for input about whether to exclude diagnostic radiopharmaceuticals from the list of items that are not paid separately when their estimated day cost is greater than the threshold as applies to other non-passthrough drugs and biologicals. Specifically, CMS sought comments on the following 5 action items:

1. Paying separately for diagnostic radiopharmaceuticals with per-day costs above the OPPS drug packaging threshold of $140
2. Establishing a specific per-day cost threshold that may be greater or less than the OPPS drug packaging threshold
3. Restructuring APCs, including by adding nuclear medicine APCs for services that utilize high-cost diagnostic radiopharmaceuticals
4. Creating specific payment policies for diagnostic radiopharmaceuticals used in clinical trials
5. Adopting codes that incorporate the disease state being diagnosed or a diagnostic indication of a particular class of diagnostic radiopharmaceuticals.

The agency indicated it has always believed diagnostic radiopharmaceuticals were intended to be used in nuclear medicine procedures as supplies for diagnostic procedures, and therefore, packaged into the primary service. The continued growing expense of diagnostic radiopharmaceuticals continues to impose limitations for many hospitals, especially when there is no payment comparable to the expense.

For 2025, CMS will pay separately for any diagnostic radiopharmaceutical with a per-day cost greater than $630. Any diagnostic radiopharmaceutical with a per-day cost of less than $630 would continue to be packaged under the current policy.

Beginning in CY 2026 and subsequent years, CMS will update the threshold amount of $630 by the PPI for Pharmaceuticals for Human Use (Prescription) (Bureau of Labor Statistics series code WPUSI07003) from IHS Global, Inc (IGI).

CMS has indicated that within the addendum payment files it identifies, the diagnostic radiopharmaceuticals that exceed the proposed threshold of $630 are marked with status indicator K for easy identification.

Invoice Pricing for Drugs

In recent years, there have been more drugs and biologicals HCPCS codes that do not have average sales price (ASP), wholesale acquisition cost (WAC), average wholesale priced (AWP), and mean unit cost (MUC) data available. The vendor also may not have any sales data, even though there is a HCPCS code for marketing. Typically, this scenario is for new drugs and biologicals and it presents an issue for CMS to establish payment status indicators. The volume of codes has continued to rise from 77 drugs and biologicals in CY 2022, 85 in CY 2023, and 109 in CY 2024.

Beginning in CY 2026, CMS will utilize an invoice pricing policy. For CY 2025, affected drugs and biologicals will continue to be assigned a nonpayable status indicator until CMS implements the invoice pricing policy. For the drugs that CMS does not have data for, Addendum B of the ruling will identify for the Medicare Administrative Contractors (MACs) which drugs would be invoice priced and the MAC would then calculate payment based on the invoice.

The drug or biological invoice cost would be the net acquisition cost minus any rebates, chargebacks, or post-sale concessions. First, MACs would use the provider invoice to determine if the following criteria are met: (a) the drug is not policy packaged and (b) the per-day cost of the drug, biological, therapeutic radiopharmaceutical, or diagnostic radiopharmaceutical is above the threshold packaging amount, as applicable.

CMS expects pricing to be temporary, lasting 2 to 3 quarters until the required ASP for qualified drugs can be reported by the vendor. For those drugs not required to report ASP, (ie, diagnostic radiopharmaceuticals) it may take longer until an MUC can be calculated. To be ready for CY 2026, CMS indicated it would be working with the National Uniform Billing Committee to create a value code that would allow for the reporting of invoice prices of drugs, biologicals, and radiopharmaceuticals for purposes of this policy.

340B Drug Discount Program

As previously mentioned, CMS is finalizing its proposal to continue to reimburse drugs and biologicals purchased under a 340B program at the default rate of ASP plus 6%. Due to litigation with previous 340B payment policies between the years of 2018 through 2022, CMS has published separate proposed and final rules to remedy the reduced payment amounts during these years. The HOPPS 2025 final rule does not affect payment policy for 340B acquired drugs in 2024. However, CMS initially proposed changes to adjust the conversion factor beginning in CY 2025 by –0.5% annually until the estimated total offset of $7.8 billion was reached in a budget-neutral manner.

At the time of that proposed rule, CMS estimated this process would take 16 years. However, this estimate would be adjusted in future CY annual HOPPS rules after CY 2025. CMS believes that starting the reduction in CY 2025 would allow the agency time to finalize and apply the methodology to calculate and publish rates and allow affected parties to prepare for the new payment rates. CMS sought comments on CY 2026 as an alternative start date of this required financial offset on impacted hospitals. After consideration of the comments received, CMS finalized the start date of CY 2026 to adjust the conversion factor by –0.5% on an annual basis until the entire $7.8 million is compensated over 16 years (estimation by CMS). This final rule can be located on the CMS website: CMS-1793-F.

With the HOPPS final rule, it’s not expected that there will be any changes mandated by Congress, as there potentially may be for the MPFS. Instead, any changes are likely to come at the end of 2024 due to errors found in the files and release of a correction notice.

Teri Bedard, BA, RT(R)(T), CPC, is executive director of client and corporate resources at Revenue Cycle Coding Strategies in Des Moines, Iowa.

Reference

1. Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems; Quality Reporting Programs, including the Hospital Inpatient Quality Reporting Program; etc. November 27, 2024. Accessed December 3, 2024. https://www.federalregister.gov/public-inspection/2024-25521/medicare-and-medicaid-programs-hospital-outpatient-prospective-payment-and-ambulatory-surgical

CY 2025 MPFS Final Rule Highlights

On November 1, 2024, the Centers for Medicare & Medicaid Services (CMS) released the final rules for the calendar year (CY) 2025 Medicare Physician Fee Schedule (MPFS).1 Once again, the main highlights of the MPFS are a reduction in the conversion factor (CF), a reduction in payments, and final transitions from the extensions and waivers related to the COVID-19 public health emergency (PHE). It should be noted that there has been legislation introduced to offset the reimbursement reductions for physicians and office settings, but most likely nothing will be decided until after the beginning of CY 2025.

MPFS Payment Rates

MPFS provides regulatory information and payment rates for physicians, no matter what setting they work in (facility and non-facility) or who employs them.

The conversion factor is a value set each year; it converts the relative value units (RVUs) of physician work, practice expense, and malpractice (practice liability insurance) of each code and their geographic locations into the assigned CMS payment rate, which is determined by building on the CF from the preceding year. As defined in previous legislation, the CF has a statutory increase of 0% through CY 2025. Any adjustments are solely due to other regulatory constraints or for maintenance of the Medicare budget.

For CY 2025, CMS was required, per the consolidated Appropriations Act of 2023 (CAA 2023), to first reduce the CY 2024 CF ($33.2875) by 2.93% to determine the base value to begin the 2025 calculations. The decrease was a result of the one-time-only increase legislated for CY 2025 CF; the CF base for 2024 was $32.3400. CMS did finalize a slight increase to budget neutrality of 0.02%. Considering these factors, CMS finalized a CF of $32.3565, an estimated 2.91% decrease from 2024. Below is the breakdown between facility and non-facility settings, as estimated per the total allowed charges for CY 2025.

• Hematology/Oncology combined impact: total impact: –1%, non-facility impact: –1%, and facility impact: 0%
• Radiation oncology and radiation therapy centers combined impact: total impact: 0%, non-facility impact: –1%, and facility impact: 2%

The lowering of the CF results in decreases for many specialties and their estimated impacts; however, additional decreases are proposed to RVUs due to potentially misvalued codes, year 4 of the clinical labor pricing update, and proposed adjustments to transfer of postoperative care for global surgical procedures.

Specific Codes and Code Set Valuations

Within the CY 2025 proposed and final MPFS rule, CMS addressed multiple misvalued and/or proposed value changes to specific series of new and established Current Procedure Terminology (CPT®) codes. CMS sought input from interested parties on 5 potentially misvalued codes. CMS explains that its rationale for the potential changes is based on values recommended by the Relative Value Scale Update Committee (RUC) and other organizations that CMS relies on for assistance when setting appropriate values for codes.

Hyperthermic Intraperitoneal Chemotherapy

CPT code 96547 is for an intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC) procedure, including separate incision(s) and closure, when performed; it is inclusive of the first 60 minutes. CPT code 96548 is for the HIPEC procedure, including separate incision(s) and closure, when performed; it is inclusive of each additional 30 minutes (list separately in addition to the code for the primary procedure). These codes were created in September 2022 to report HIPEC procedures for 2024. At the January 2023 RUC meeting, the RUC believed the survey data were flawed due to a lack of work definition and guidelines, and therefore, the RUC recommended contractor pricing for these codes for CY 2024. Subsequently, CMS proposed and finalized contractor pricing for codes 96547 and 96548 for CY 2024.

For CY 2025, CMS finalized, as proposed, the work RVU and direct PE (practice expense) inputs; the RUC-recommended work RVU of 6.53 for CPT code 96547 and the RUC-recommended work RVU of 3.00 for CPT code 96548. The RUC did not recommend, and CMS did not propose, any direct PE inputs.

CAR T-Cell Therapy Services

In September 2023, the CPT Editorial Panel deleted 4 category III codes (0537T-0540T) and approved the addition of 4 new codes (38225-38228) that describe only steps of the complex CAR T-cell therapy process that are performed and supervised by physicians. The RUC recommended 4 different work RVUs for codes 38225, 38226, 38227, and 38228 and only recommended direct PE values for code 38228.

For CY 2025, CMS proposed to recognize the RUC-recommended work RVUs for CPT codes 38225, 38226, and 38227. However, CMS did not finalize this proposal, instead aligning with payment methodology under the Hospital Outpatient Prospective Payment System (HOPPS) for the same set of codes. Where these services are not paid separately, under the MPFS, CMS will bundle the payment for codes 38225, 38226, and 38227. CMS will display the RUC-recommended work RVUs for the 3 services, as it does for other bundled services, but will make no separate payment. CPT code 38228 replaced category III code 0504T, which was not bundled, as the other previous category III codes were. Because of this, CMS finalized the proposed values for work RVUs and direct PE inputs and set pricing for CPT code 38228, which will be considered active.

Telemedicine E/M Services

In the MPFS proposed rule for CY 2025, CMS addressed the 17 new codes from the American Medical Association (AMA) for telemedicine services.

In February 2023, the CPT Editorial Panel added a new Evaluation and Management (E/M) subsection to the draft CPT codebook for telemedicine services. The panel added 17 codes for reporting telemedicine E/M services. The new codes include 4 new patient synchronous audio-video visits (98000 98003), 4 new patient audio-only visits (98008-98011), 4 established patient synchronous audio-video visits (98004-98007), and 4 established patient audio-only visits (98012-98015) for a total of 16 new codes. The last code is CPT 98016, which is a brief communication, technology-based, virtual check in code.

With the addition of these new telehealth codes, the AMA CPT Editorial Panel deleted the current audio-only CPT codes (99441-99443) effective January 1, 2025.

CMS reiterated that there are already services listed in the Medicare List of Telehealth Services and identified which services can be provided by audio-video and audio-only methodology. If the agency were to incorporate the AMA
codes, CMS would have to value RVUs to each telemedicine service. Two values, 1 for telehealth and 1 for in-person visits, would be required.

For CY 2025, CMS finalized not to recognize CPT codes 98000-98015 and instead assigned them a procedure status indicator of I, which means there is a more specific code (ie, existing office/outpatient E/M codes 99202-99215) to be used for Medicare. Additionally, providers will need to continue to utilize modifiers (93 and/or 95) and place of service (POS) codes (02 or 10), as defined by Medicare, to identify the correct location of the patient (if applicable) for payments, as Medicare will not be paying for the 16 new telemedicine codes.

The Consolidated Appropriations Act of 2023 (CCA 2023) allows for Medicare beneficiaries to be located anywhere in the US and to receive telehealth services through December 31, 2024. According to Medicare, effective January 1, 2025, the beneficiary’s location and site-of-service restrictions on Medicare telehealth services will once again take effect (ie, return to prepandemic guidelines). Even though there are new telehealth codes from the AMA, this does not mean that CMS is required to recognize and reimburse the codes for telehealth services.

There will be a few exceptions. Behavioral health services and end-stage renal disease-related clinical assessments are excluded from reverting back to the prepandemic telehealth policy. Telehealth services for any Medicare beneficiaries/patients will only be available in rural areas, and only when the patient is in certain types of medical settings.

After reviewing the comments received, CMS did not feel they were persuasive in the need for CMS to recognize and separately pay for the 16 new telemedicine CPT codes (98000-98015). CMS determined that the current outpatient codes already in use (which CMS does recognize for telemedicine with the use of a modifier and place-of-service [POS] codes) were not distinctly different and, therefore, it was not necessary for CMS to recognize them.

Separately, the new brief communication, virtual check-in code 98016 was proposed and finalized and will be implemented by CMS. Therefore, CMS is deleting HCPCS G2012, effective January 1, 2025, and has accepted the RUC-recommended values work RVU of 0.30 and direct PE inputs for 98016.

Payment for Telehealth Services

Radiation Therapy Management

Currently, radiation therapy management (77427) is on the Medicare List of Telehealth Services with provisional status and was expected to end December 31, 2024. It was requested that this service be permanently added since it has routinely been performed remotely, thereby proving it is a safe option. Another request was for the code to be removed from the list due to concerns that in-person care was necessary to address adverse effects of radiation therapy. Based on these concerns, CMS proposed to remove this service from the telehealth list and has requested further comment on the extent of these concerns.

For CY 2025, CMS finalized its decision to maintain CPT 77427 on the list on a provisional basis. Those in support of maintaining the code have indicated there have been no published safety incidents since 77427 was provisionally added to the list, and that most of the adverse effects associated with radiation therapy treatment delivery were minor dermatological issues that could be treated via audio-video technology. CMS did indicate that it recognizes the ongoing safety concerns and welcomes any information on adverse outcomes when it becomes available.

Care Management Visits

Currently, care management visits (CPT 99484, 99424-99427) are not on the Medicare List of Telehealth Services, nor have these services ever been added or removed. CMS determined through the 5-step process that these codes are not telehealth services and, as such, CMS did not propose to add these codes to the list. CMS did not receive any comments about these codes; therefore, the agency is finalizing as proposed to not include the services on the approved List of Telehealth Services.

Physician Supervision via Two-Way Audio/Video

Direct supervision requires the immediate availability of the physician in the office suite, but physicians are not required to be present in the same room. In previous rule making, CMS has established immediate availability to mean in-person, physical (not virtual) availability. During COVID-19 PHE, CMS adjusted the definition for direct supervision, as it pertains to supervision of diagnostic tests, physicians’ services, and some hospital outpatient services, to allow the supervising professional to be immediately available through virtual presence using two-way, real-time audio/video technology, instead of their physical presence. The option to use real-time audio/video capabilities was expected to expire on December 31, 2024.

For CY 2025, CMS proposed and finalized an incremental approach to changes. The agency is temporarily extending and defining direct supervision and immediate availability of the supervising practitioner through real-time audio and visual interactive telecommunications (excluding audio-only) through December 31, 2025. CMS proposed and finalized permanently extending the ability to provide direct supervision using audio/video capabilities for a subset of services that the agency indicates are performed entirely by auxiliary personnel. The subset of indicated services have been assigned the PC/TC indicator of 5 within the CMS RVU file and CPT 99211 (office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician or other qualified health care professional)which does not require the physician’s presence or participation for staff to provide the service.

The final language from CMS is as follows: “…for the following services furnished after December 31, 2025, the presence of the physician (or other practitioner) required for direct supervision shall continue to include virtual presence through audio/video real-time communications technology (excluding audio-only): services furnished incident to a physician’s service when they are provided by auxiliary personnel employed by the physician and working under his or her direct supervision and for which the underlying HCPCS code has been assigned a PC/TC indicator of ‘5’; and office and other outpatient visits for the evaluation and management of an established patient that may not require the presence of a physician or other qualified health care professional. We note that, in instances where a service on the Medicare telehealth list, is available to beneficiaries in their homes, and also has the requirement of direct supervision, that under the applicable definition of direct supervision, the physician/practitioner is required to be available using both audio and video. We note that does not necessarily mean that any interaction between the patient and the physician/practitioner supervising the service would require a video component.”

In CY 2024, the list of services currently assigned PC/TC number 5 are predominantly therapeutic, chemotherapy injections, and infusions. The list for CY 2025 is not expected to be released until the end of 2024.

Residents in Teaching Settings

In previous rule making, CMS established a policy that allows teaching physicians to fulfil supervision requirements to be present for the key or critical portions of services through audio/video real-time communications technology when services are provided by a resident. This policy was only valid for services furnished in residency training sites outside of an Office of Management and Budget-defined as a metropolitan statistical area. This distinction was made to increase beneficiary access to Medicare-covered services in rural areas.

For CY 2025, CMS will continue to allow the teaching physician to have a virtual presence in all teaching settings, but only in clinical instances when the service is furnished virtually (3-way telehealth visit, with all parties in separate locations). This allows teaching physicians to have a virtual presence during the key portion of the Medicare telehealth service through real-time audio/video communication for all residency training locations extended through December 31, 2025.

Drugs and Biologicals Paid Under Medicare Part B

Drug Waste Billing

CMS updated the JW Modifier and JZ Modifier Policy FAQ on October 16, 2023. Since then, it has received requests for clarification on how to appropriately bill for discarded amounts from single-dose containers when there are amounts discarded during preparation by the billing supplier, who does not administer the drug. Related to modifiers -JW and -JZ, billing suppliers and billing providers who prepare but do not administer the drug are subject to the billing requirements. CMS clarified the following definitions:

• Supplier: A physician or other practitioner, or an entity other than a provider, that furnishes health care services under Medicare.
• Provider: A hospital; critical access hospital (CAH); skilled nursing facility; comprehensive outpatient rehabilitation facility; home health agency; hospice; or clinic, rehabilitation agency, or public health agency that furnishes outpatient physical therapy or speech pathology services, all of which must have an agreement to participate in Medicare (defined in § 400.202). Additionally, this includes community mental health centers with a similar agreement to provide partial hospitalization services.

For CY 2025, CMS proposed and finalized that modifier JW is required when a billing supplier is not administering a drug but discards drug amounts during the preparation process before supplying it to the patient. Modifier JZ is required if no drug amounts are discarded during preparation.

Even though CMS has finalized the MPFS rules for 2025, it is possible that things could change. Any change would have to be directed by Congress. For example, on October 29, 2024, the Medicare Patient Access and Practice Stabilization Act of 2024 was introduced in the House of Representatives. The bill outlines elimination of the 2.8% conversion cut and provides additional updates. With the budget still up in the air for FY 2025, any changes to physician payments may not be set until the first 3 months of CY 2025.

Teri Bedard, BA, RT(R)(T), CPC, is executive director of client and corporate resources at Revenue Cycle Coding Strategies in Des Moines, Iowa.

Reference

1. CMS. Medicare and Medicaid Programs: Calendar Year 2025 Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies; Medicare Shared Savings Program Requirements; Medicare Prescription Drug Inflation Rebate Program; Medicare Overpayments. Scheduled to be published December 9, 2024. Accessed December 5, 2024. https://www.federalregister.gov/
   public-inspection/2024-25382/medicare-and-medicaid-programs-calendar-year-2025-payment-policies-under-the-physician-fee-schedule

2025 Oncology Coding Update

The coding updates for 2025 have been released by both the American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS). There are several new codes for telemedicine evaluation and management (E/M) services that Medicare has decided not to recognize, but these codes will be available for private payers. There are other revisions to keep you up-to-date for CY 2025. This article outlines coding changes specific to the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) and Current Procedural Terminology (CPT®) and the Healthcare Common Procedure Coding System (HCPCS) for services that may be provided by or related to services by oncology specialties. Items in bold highlight the changes for 2025.

REVISED ICD-10-CM GUIDELINES

The following ICD-10-CM guidelines went into effect October 1, 2024, as the updates run on the fiscal year calendar. Due to the change to a biannual update to diagnosis coding, additional updates are expected for implementation on April 1, 2025. Many of the guidelines updated for 2024 focus on the need to code the diagnosis to the highest level of specificity. Language was used in several sections of the ICD-10-CM Official Guidelines to press this point. The guidelines state the following new language in 2025:

Chapter 2: Neoplasms (C00-D49)

• Breast Implant Associated Anaplastic Large Cell Lymphoma. Breast implant associated anaplastic large cell lymphoma (BIA-ALCL) is a type of lymphoma that can develop around breast implants. Assign code C84.7A, Anaplastic large cell lymphoma, ALK-negative, breast, for BIA-ALCL or C84.7B, Anaplastic large cell lymphoma, ALK-negative, in remission, for BIA-ALCL in remission. Do not assign a complication code from chapter 19.
• Secondary malignant neoplasm of lymphoid tissue. When a malignant neoplasm of lymphoid tissue metastasizes beyond the lymph nodes, a code from categories C81-C85 with a final character identifying “extranodal and solid organ sites” should be assigned rather than a code for the secondary neoplasm of the affected solid organ. For example, for metastasis of diffuse large B-cell lymphoma to the lung, brain, and left adrenal gland, assign code C83.398, Diffuse large B-cell lymphoma of other extranodal and solid organ sites.

Chapter 21: Factors Influencing Health Status and Contact With Health Services (Z00-Z99)

• The status Z codes/categories. Z17: Estrogen, and other hormones and factors receptor status.

REVISED ICD-10-CM CODES

The codes available continue to expand to allow for specificity with diagnosis coding. Codes related to Hodgkin’ Lymphoma were expanded with many new codes to identify remission status. The following are highlights of ICD-10-CM coding changes for 2025; ICD-10-CM codes in orange have been added and codes that are struck through have been deleted.

Chapter 2: Neoplasms (C00-D49)

• Malignant neoplasms of breast (C50)
  • C50: Malignant neoplasm of breast
  • Use Additional
    Revise from - code to identify estrogen receptor status (Z17.0, Z17.1) Revise to - code to identify estrogen, and other hormones and factors receptor status (Z17.-)
• Malignant neuroendocrine tumors (C7A)
  • C7A: Malignant neuroendocrine tumors
  • Use Additional
    Revise from - carcinoid syndrome (E34.0)
    Revise to - carcinoid syndrome (E34.00)
• Malignant neoplasms of lymphoid, hematopoietic, and related tissue (C81-C96)
  • C81: Hodgkin lymphoma
    • C81.0A: Nodular lymphocyte predominant Hodgkin lymphoma, in remission
    • C81.1A: Nodular sclerosis Hodgkin lymphoma, in remission
    • C81.2A: Mixed cellularity Hodgkin lymphoma, in remission
    • C81.3A: Lymphocyte depleted Hodgkin lymphoma, in remission
    • C81.4A: Lymphocyte-rich Hodgkin lymphoma, in remission
    • C81.7A: Other Hodgkin lymphoma, in remission
    • C81.9A: Hodgkin lymphoma, unspecified, in remission
    • C82: Follicular lymphoma
    • C82.0A: Follicular lymphoma grade I, in remission
    • C82.1A: Follicular lymphoma grade II, in remission
    • C82.2A: Follicular lymphoma grade III, unspecified, in remission
    • C82.3A: Follicular lymphoma grade IIIa, in remission
    • C82.4A: Follicular lymphoma grade IIIb, in remission
    • C82.5A: Diffuse follicle center lymphoma, in remission
    • C82.6A Cutaneous follicle center lymphoma, in remission
    • C82.8A: Other types of follicular lymphoma, in remission
    • C82.9A: Follicular lymphoma, unspecified, in remission
  • C83:Non-follicular lymphoma
    • C83.0 Small cell B-cell lymphoma
    • Excludes 1:
      • Revise from - Waldenström macroglobulinemia (C88.0)
        Revise to - Waldenström macroglobulinemia (C88.00)
    • C83.0A: Small cell B-cell lymphoma, in remission
    • C83.1: Mantle cell lymphoma
      • C83.1A: Mantle cell lymphoma, in remission
        Centrocytic lymphoma, in remission
    • C83.3: Diffuse large B-cell lymphoma
  • C83.39: Diffuse large B-cell lymphoma, extranodal and solid organ sites
    • C83.390: Primary central nervous system lymphoma
      • PCNSL of brain
      • PCNSL of meninges
      • PCNSL of spinal cord
      • PCNSL NOS
      • Excludes 1: Primary central nervous system lymphoma,
      • Burkitt (C83.79)
        • Primary central nervous system lymphoma, lymphoblastic (C83.59)
        • Primary central nervous system lymphoma, other (C83.89)
        • Primary central nervous system lymphoma, peripheral T-cell (C84.49)
    • C83.398: Diffuse large B-cell lymphoma of other extranodal and solid organ sites
    • C83.3A: Diffuse large B-cell lymphoma, in remission
    • C83.5A: Lymphoblastic (diffuse) lymphoma, in remission
    • C83.7A: Burkitt lymphoma, in remission
    • C83.8A: Other non-follicular lymphoma, in remission
    • C83.9A: Non-follicular (diffuse) lymphoma, unspecified, in remission
  • C84: Mature T/NK-cell lymphomas
    • C84.0A: Mycosis fungoides, in remission
    • C84.1A: Sézary disease, in remission
    • C84.4A: Peripheral T-cell lymphoma, not elsewhere classified, in remission
    • C84.6A: Anaplastic large cell lymphoma, ALK-positive, in remission
    • C84.7B: Anaplastic large cell lymphoma, ALK-negative, in remission
    • C84.AA: Cutaneous T-cell lymphoma, unspecified, in remission
  • C84.Z: Other mature T/NK-cell lymphomas
    • Excludes 1:
      • Angioimmunoblastic T-cell lymphoma (C86.50)
      • Blastic NK-cell lymphoma (C86.40)
      • Enteropathy-type T-cell lymphoma
        (C86.20)
      • Extranodal NK-cell lymphoma, nasal type (C86.00)
      • Hepatosplenic T-cell lymphoma (C86.10)
      • Primary cutaneous CD30-positive T-cell proliferations (C86.60)
      • Subcutaneous panniculitis-like T-cell lymphoma (C86.30)
    • C84.ZA: Other mature T/NK-cell lymphomas, in remission
  • C84.9 Mature T/NK-cell lymphomas, unspecified
    • C84.9A: Mature T/NK-cell lymphomas, unspecified, in remission
  • C85: Other specified and unspecified types of non-Hodgkin lymphoma
    • C85.1A: Unspecified B-cell lymphoma, in remission
    • C85.2A: Mediastinal (thymic) large B-cell lymphoma, in remission
    • C85.8A: Other specified types of non-Hodgkin lymphoma, in remission
    • C85.9A: Non-Hodgkin lymphoma, unspecified, in remission
    • C86.00: Extranodal NK/T-cell lymphoma, nasal type not having achieved remission
      • Extranodal NK/T-cell lymphoma, nasal type NOS
      • Extranodal NK/T-cell lymphoma
    • C86.01: Extranodal NK/T-cell lymphoma, nasal type, in remission
  • C86.1: Hepatosplenic T-cell lymphoma
    • C86.10: Hepatosplenic T-cell lymphoma not having achieved remission
      • Hepatosplenic T-cell lymphoma NOS
      • Hepatosplenic T-cell lymphoma
        with failed remission
    • C86.11: Hepatosplenic T-cell lymphoma, in remission
  • C86.2: Enteropathy-type (intestinal) T-cell lymphoma
    • C86.20: Enteropathy-type (intestinal) T-cell lymphoma not having achieved remission
      • Enteropathy associated T-cell lymphoma NOS
      • Enteropathy associated T-cell lymphoma not having achieved remission
      • Enteropathy associated T-cell lymphoma with failed remission
      • Enteropathy-type (intestinal) T-cell lymphoma NOS
      • Enteropathy-type (intestinal) T-cell lymphoma with failed remission
    • C86.21: Enteropathy-type (intestinal) T-cell lymphoma, in remission
      • Enteropathy associated T-cell lymphoma, in remission
  • C86.3: Subcutaneous panniculitis-like T-cell
    lymphoma
    • C86.30: Subcutaneous panniculitis-like
      T-cell lymphoma not having achieved
      remission
      • Subcutaneous panniculitis-like T-cell lymphoma NOS
      • Subcutaneous panniculitis-like T-cell lymphoma with failed remission
    • C86.31: Subcutaneous panniculitis-like T-cell lymphoma, in remission
  • C86.4: Blastic NK-cell lymphoma
    • C86.40: Blastic NK-cell lymphoma not having achieved remission
      • Blastic NK-cell lymphoma NOS
      • Blastic NK-cell lymphoma with failed remission
      • Blastic plasmacytoid dendritic cell neoplasm (BPDCN) NOS
      • Blastic plasmacytoid dendritic cell neoplasm (BPDCN) not having achieved remission
    • C86.41: Blastic NK-cell lymphoma, in remission
      • Blastic plasmacytoid dendritic cell neoplasm (BPDCN), in remission
  • C86.5: Angioimmunoblastic T-cell lymphoma
    • C86.50: Angioimmunoblastic T-cell lymphoma not having achieved remission
      • Angioimmunoblastic lymphadenopathy with dysproteinemia (AILD) NOS
      • Angioimmunoblastic lymphadenopathy with dysproteinemia (AILD) not having achieved remission
      • Angioimmunoblastic lymphadenopathy with dysproteinemia (AILD) with failed remission
      • Angioimmunoblastic T-cell lymphoma NOS
      • Angioimmunoblastic T-cell lymphoma with failed remission
    • C86.51: Angioimmunoblastic T-cell lymphoma, in remission
      • Angioimmunoblastic lymphadenopathy with dysproteinemia (AILD), in remission
  • C86.6: Primary cutaneous CD30-positive T-cell proliferations
    • C86.60: Primary cutaneous CD30-positive T-cell proliferations not having achieved remission
      • Lymphomatoid papulosis NOS
      • Lymphomatoid papulosis not having achieved remission
      • Lymphomatoid papulosis with failed remission
      • Primary cutaneous anaplastic large cell lymphoma NOS
      • Primary cutaneous anaplastic large cell lymphoma not having achieved remission
      • Primary cutaneous anaplastic large cell lymphoma with failed remission
      • Primary cutaneous CD30-positive large T-cell lymphoma NOS
      • Primary cutaneous CD30-positive large T-cell lymphoma not having achieved remission
      • Primary cutaneous CD30-positive large T-cell lymphoma with failed remission
      • Primary cutaneous CD30-positive T-cell proliferations NOS
      • Primary cutaneous CD30-positive T-cell proliferations with failed remission
    • C86.61: Primary cutaneous CD30-positive T-cell proliferations, in remission
  • C88: Malignant immunoproliferative diseases and certain other B-cell lymphomas
  • C88.0: Waldenström macroglobulinemia
    • C88.00: Waldenström macroglobulinemia not having achieved remission
      • Lymphoplasmacytic lymphoma with IgM-production, NOS
      • Lymphoplasmacytic lymphoma with IgM-production not having achieved remission
      • Lymphoplasmacytic lymphoma with IgM-production with failed remission
      • Macroglobulinemia (idiopathic) (primary) NOS
      • Macroglobulinemia (idiopathic) (primary) not having achieved remission
      • Macroglobulinemia (idiopathic) (primary) with failed remission
      • Waldenström macroglobulinemia NOS
      • Waldenström macroglobulinemia with failed remission
    • C88.01: Waldenström macroglobulinemia, in remission
  • C88.4: Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue [MALT- lymphoma]
    • C88.40: Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue [MALT-lymphoma] not achieved remission
      • Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue [MALT- lymphoma] NOS
      • Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue [MALT- lymphoma] with failed remission
      • Lymphoma of bronchial-associated lymphoid tissue [BALT-lymphoma] NOS
      • Lymphoma of bronchial-associated lymphoid tissue [BALT-lymphoma] not having achieved remission
      • Lymphoma of bronchial-associated lymphoid tissue [BALT-lymphoma] with failed remission
      • Lymphoma of skin-associated lymphoid tissue [SALT-lymphoma] NOS
      • Lymphoma of skin-associated lymphoid tissue [SALT-lymphoma] not having achieved remission
      • Lymphoma of skin-associated lymphoid tissue [SALT-lymphoma] with failed remission
    • C88.41: Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue [MALT-lymphoma], in remission
  • C88.8: Other malignant immunoproliferative diseases
    • C88.80: Other malignant immunoproliferative diseases not having achieved remission
      • Other malignant immunoproliferative diseases NOS
      • Other malignant immunoproliferative diseases with failed remission
    • C88.81: Other malignant immunoproliferative diseases, in
      remission
  • C88.9: Malignant immunoproliferative disease, unspecified
    • C88.90: Malignant immunoproliferative disease, unspecified not having achieved remission
      • Immunoproliferative disease NOS
      • Immunoproliferative disease NOS not having achieved remission
      • Immunoproliferative disease NOS with failed remission
      • Malignant immunoproliferative disease, unspecified NOS
      • Malignant immunoproliferative disease, unspecified with failed remission
    • C88.91: Malignant immunoproliferative disease, unspecified, in remission
• In situ neoplasms (D00-D09)
  • D05: Carcinoma in situ of breast
    • Excludes2: malignant neoplasm of breast (C50.-)
  • Benign neuroendocrine tumors (D3A)
    • D3A: Benign neuroendocrine tumors
      • Use Additional
      • Revise from - carcinoid syndrome (E34.0)
      • Revise to - carcinoid syndrome (E34.00)

CPT CODING UPDATES

Evaluation and Management (E/M) Revised Codes

Listed below are 17 new telemedicine evaluation and management (E/M) codes for CY 2025. As mentioned previously, Medicare will not be reimbursing 16 of the new codes, unless there is future direction by Congress. Medicare will continue to accept the outpatient/office E/M visits with appropriate modifiers and place of service codes. Medicare is recognizing the virtual brief check-in code created by the American Medical Association (AMA) and deleting HCPCS G2012 due to this acceptance.

New Patient Audio-Video Visits

• 98000: Synchronous audio-video visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision-making. When using total time on the date of the encounter for code selection, 15 minutes must be met or exceeded.
• 98001: Synchronous audio-video visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low medical decision-making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.
• 98002: Synchronous audio-video visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate medical decision-making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded.
• 98003: Synchronous audio-video visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and/or examination and high medical decision-making. When using total time on the date of the encounter for code selection, 60 minutes must be met or exceeded. (For services 75 minutes or longer, use prolonged services code 99417.)

Established Patient Audio-Video Visits

• 98004: Synchronous audio-video visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision-making. When using total time on the date of the encounter for code selection, 10 minutes must be met or exceeded.
• 98005: Synchronous audio-video visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low medical decision-making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded.
• 98006: Synchronous audio-video visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate medical decision-making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.
• 98007: Synchronous audio-video visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high medical decision-making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded. (For services 55 minutes or longer, use prolonged services code 99417.)

New Patient Audio-Only Visits

• 98008: Synchronous audio-only visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination, straightforward medical decision-making, and more than 10 minutes of medical discussion. When using total time on the date of the encounter for code selection, 15 minutes must be met or exceeded.
• 98009: Synchronous audio-only visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination, low medical decision-making, and more than 10 minutes of medical discussion. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.
• 98010: Synchronous audio-only visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination, moderate medical decision-making, and more than 10 minutes of medical discussion. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded.
• 98011: Synchronous audio-only visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination, high medical decision-making, and more than 10 minutes of medical discussion. When using total time on the date of the encounter for code selection, 60 minutes must be met or exceeded. (For services 75 minutes or longer, use prolonged services code 99417.

Established Patient Audio-Only Visits

• 98012: Synchronous audio-only visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination, straightforward medical decision-making, and more than 10 minutes of medical discussion. When using total time on the date of the encounter for code selection, 10 minutes must be exceeded.
• 98013: Synchronous audio-only visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination, low medical decision-making, and more than 10 minutes of medical discussion. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded.
• 98014: Synchronous audio-only visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination, moderate medical decision-making, and more than 10 minutes of medical discussion
• When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.
• 98015: Synchronous audio-only visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination, high medical decision-making, and more than 10 minutes of medical discussion. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded. (For services 55 minutes or longer, use prolonged services code 99417.)

Brief Communication Check-In

• 98016: Brief communication technology-based service (eg, virtual check-in) by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related evaluation and management service provided within the previous 7 days nor leading to an evaluation and management service or procedure within the next 24 hours or soonest available appointment, 5-10 minutes of medical discussion.

E/M New Codes

Chimeric Antigen Receptor T-Cell (CAR T-cell) therapy utilized Category III codes for billing. Effective for CY 2025, the Category III codes are being deleted and CPTcodes 38225, 38226, 38227, and 38228 are replacing these codes.

• 38225: Chimeric antigen receptor T-cell (CAR-T) therapy; harvesting of blood-derived T lymphocytes for development of genetically modified autologous CAR-T cells, per day
• 38226: Chimeric antigen receptor T-cell (CAR-T) therapy; preparation of blood-derived T lymphocytes for transportation (eg, cryopreservation, storage)
• 38227: Chimeric antigen receptor T-cell (CAR-T) therapy; receipt and preparation of CAR-T cells for administration
• 38228: Chimeric antigen receptor T-cell (CAR-T) therapy; CAR-T cell administration, autologous

The AMA CPT Editorial Panel created 6 codes to report magnetic resonance (MR) examination safety procedures, which may be applicable in radiation oncology for MR-based linear accelerators, effective January 1, 2025. The new codes did not have a predecessor code or a one-to-one match to an existing code.

• 76014: MR safety implant and/or foreign body assessment by trained clinical staff, including identification and verification of implant components from appropriate sources (eg, surgical reports, imaging reports, medical device databases, device vendors, review of prior imaging), analyzing current MR conditional status of individual components and systems, and consulting published professional guidance with written report; initial 15 minutes
• 76015: MR safety implant and/or foreign body assessment by trained clinical staff, including identification and verification of implant components from appropriate sources (eg, surgical reports, imaging reports, medical device databases, device vendors, review of prior imaging), analyzing current MR conditional status of individual components and systems, and consulting published professional guidance with written report; each additional 30 minutes (list separately in addition to code for primary procedure)
• 76016: MR safety determination by a physician or other qualified health care professional responsible for the safety of the MR procedure, including review of implant MR conditions for indicated MR examination, analysis of risk vs clinical benefit of performing MR examination, and determination of MR equipment, accessory equipment, and expertise required to perform examination, with written report
• 76017: MR safety medical physics examination customization, planning and performance monitoring by medical physicist or MR safety expert, with review and analysis by physician or other qualified health care professional to prioritize and select views and imaging sequences, to tailor MR acquisition specific to restrictive requirements or artifacts associated with MR conditional implants or to mitigate risk of non-conditional implants or foreign bodies, with written report
• 76018: MR safety implant electronics preparation under supervision of physician or other qualified health care professional, including MR-specific programming of pulse generator and/or transmitter to verify device integrity, protection of device internal circuitry from MR electromagnetic fields, and protection of patient from risks of unintended stimulation or heating while in the MR room, with written report
• 76019: MR safety implant positioning and/or immobilization under supervision of physician or other qualified health care professional, including application of physical protections to secure implanted medical device from MR-induced translational or vibrational forces, magnetically induced functional changes, and/or prevention of radiofrequency burns from inadvertent tissue contact while in the MR room, with written report

E/M Deleted Codes

• 0537T: Chimeric antigen receptor T-cell (CAR T) therapy; harvesting of blood-derived T lymphocytes for development of genetically modified autologous CAR T-cells, per day
• 0538T: Chimeric antigen receptor T-cell (CAR T) therapy; preparation of blood-derived T lymphocytes for transportation (eg, cryopreservation, storage)
• 0539T: Chimeric antigen receptor T-cell (CAR T) therapy; receipt and preparation of CAR T-cells of administration
• 0540T: Chimeric antigen receptor T-cell (CAR T) therapy; CAR T-cell administration, autologous

HCPCS CODING UPDATES

New and Added Codes

Medicare replaced HCPCS codes C9794 and C9795 for Biology Guided Radiation Therapy, which uses positron-emitting radiopharmaceuticals to control delivery of radiation therapy to treat primary and metastatic lung or bone tumors. Below are listed the new codes, which now allow for billing in the office setting.

• G0562: Therapeutic radiology simulation aided field setting; complex, including acquisition of PET and CT imaging data required for radiopharmaceutical-directed radiation therapy treatment planning (ie, modeling)
• G0563: Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance and real-time positron emissions–based delivery adjustments to 1 or more lesions, entire course not to exceed 5 fractions
• G0559: Postoperative follow-up visit complexity inherent to evaluation and management services addressing surgical procedure(s), provided by a physician or qualified health care professional who is not the practitioner who performed the procedure (or in the same group practice) and is of the same or of a different specialty than the practitioner who performed the procedure, within the 90-day global period of the procedure(s), once per 90-day global period, when there has not been a formal transfer of care and requires the following required elements, when possible and applicable: Read available surgical note to understand the relative success of the procedure, the anatomy that was affected, and potential complications that could have arisen due to the unique circumstances of the patient’s operation. Research the procedure to determine expected postoperative course and potential complications (in the case of doing a postop for a procedure outside the specialty). Evaluate and physically examine the patient to determine whether the postoperative course is progressing appropriately. Communicate with the practitioner who performed the procedure if any questions or concerns arise (list separately in addition to office/outpatient evaluation and management visit, new or established).

Deleted Codes

The following are HCPCS codes deleted and replaced with other codes identified above from Medicare.

• C9794: Therapeutic radiology simulation aided field setting; complex, including acquisition of pet and CT imaging data required for radiopharmaceutical-directed radiation therapy treatment planning (ie, modeling)
• C9795: Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance and real-time positron emissions-based delivery adjustments to 1 or more lesions, entire course not to exceed 5 fractions
• G2012: Brief communication technology-based service, eg, virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5 to 10 minutes of medical discussion.

Teri Bedard, BA, RT(R)(T), CPC, is executive director of client and corporate resources at Revenue Cycle Coding Strategies in Des Moines, Iowa