CMS has not published a document indicating it's adding the new 2005 CPT surgery codes to the official ASC list, but there are many codes that will affect ASCs performing these procedures on non-Medicare patients.

For clarity's and consistency's sakes, I am going to use the symbols in Appendix B of the CPT 2005 code book, which shows the actual changes to the code descriptors. New codes appear with a bullet (') revised codes are preceded with a triangle (s). New text appears underlined. Codes for which you would not report conscious sedation separately (even when performed at the same session by the same provider) are denoted with the bull's-eye ('). Revisions to the headings, notes, introductory paragraphs and cross-references are identified as such.

Now let's review some of the major CPT code changes for 2005.

Orthopedics

• 27412 Autologous chondrocyte implantation, knee. You usually perform this procedure to repair lesions of the femoral condyle and the patellofemoral joint, or to repair medial and lateral articular cartilage lesions of the distal femoral condyles or trochlea. Several weeks or months before this procedure, you take a biopsy specimen from the patient and send it out for cellular expansion of the graft. When the physician performs the graft procedure, a bed is prepared at the defect to contain the graft, and a patch of periosteum is harvested from the femur or tibia. The physician sews the patch into place on the defect to maintain a watertight seal, then implants the cultured chondrocyte material. He then seals the remainder of the pocket with fibrin glue to ensure no cell leakage occurs. Revisions: Do not report 27412 in conjunction with 20926, 27331 or 27570; for harvesting of chondrocytes, use 29870.
• 27415 Osteochondral allograft, knee, open. Revision: For arthroscopic implant of osteochondral allograft, use 29867.

The next two codes involve mosaicplasty, a resurfacing technique consisting of the transplantation of multiple, small-sized cylindrical osteochondral grafts to provide a smooth resurfaced area. The autografts and allografts are inserted to treat chondral and osteochondral defects of the weight-bearing surfaces to create hyaline or hyaline-like repair in the defect area. Small, varying-sized multiple cylindrical grafts provide almost complete coverage of the surface. If necessary, fibrocartilage grouting, stimulated by abrasion arthroplasty or sharp curettage at the base of the defect, may be performed to complete the new surface. In the allograft and autograft procedures, conical recipient tunnels are created in the defect; the graft material is delivered perpendicularly.

• 29866 Arthroscopy, knee, surgical; osteochondral autograft(s) (such as mosaicplasty; includes harvesting of the autograft). The grafts are harvested from the relatively less weight-bearing periphery of the patellofemoral joint, and the donor sites are repaired by the natural healing process. As this procedure typically requires the placement of multiple grafts, code 29866 is reported one time per procedure, regardless of the number of grafts obtained and inserted. Revision: Do not report this code in conjunction with 29870, 29871, 29874, 29875, 29877 or 29884 when performed at the same session; do not report with 29879, 29885-29887 when they are performed in the same compartment.
• 29867 Arthroscopy, knee, surgical; osteochondral allograft (such as mosaicplasty). Revisions: Do not report 29867 in conjunction with 27570, 29870, 29871, 29874, 29875, 29877 or 29884 when performed at the same session; do not report with 29879 or 29885 through 29887 when performed in the same compartment. In addition, do not report this code with 27415.
• 29868 Arthroscopy, knee, surgical; meniscal transplantation (includes arthrotomy for meniscal insertion), medial or lateral. This is an added code. In arthroscopic meniscal knee transplantation, the physician prepares the defect area by removing the damaged portion of the meniscus - the crescent-shaped fibrocartilaginous structure of the tibial plateau of the knee. The physician creates tibial tunnels or a bone trough as stabilizing structures, then inserts the meniscal graft through an arthrotomy, securing it to the stabilizing structures. Arthrotomy performed for meniscal insertion as an inherent component of the procedure should not be separately reported. Revisions: Do not report 29868 with 29870, 29871, 29874, 29875, 29880, 29883 and 29884 when performed at the same session or 29881, 29882 when performed in the same compartment. For open autologous chondrocyte implantation of the knee, use 27412. For implantation of osteochondral graft to treat articular surface defect, see 27412, 27415, 29866 and 29867. For meniscal transplantation, medial or lateral, use 29868.

Gastrointestinal

• 43257 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with delivery of thermal energy to the muscle of lower esophageal sphincter and/or gastric cardia, for treatment of gastroesophageal reflux disease. In this procedure, the physician delivers endoscopically guided radiofrequency thermal energy via electrodes in order to electrosurgically coagulate the muscle of the distal portion of the lower esophageal sphincter or gastric cardia to treat GERD. This increases lower esophageal sphincter pressure and augments the anti-reflux barrier.
• 43644 Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150cm or less). Revisions: Do not repot with 43846 or 49320.

Esophagogastroduodenoscopy (EGD) performed for a separate condition should be reported with modifier 59.

• 45391 Colonoscopy, flexible, proximal to splenic flexure; with endoscopic ultrasound examination. Revisions: Do not report with 45330, 45341, 45342, 45378, 76872.
• 45392 Colonoscopy, flexible, proximal to splenic flexure; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s). Do not report with 45330, 45341, 45342, 45378, 76872.
• 46947 Hemorrhoidopexy (for example, to treat prolapsing internal hemorrhoids) by stapling. This procedure, also called PHP (procedure for prolapse and hemorrhoids) is an added code. An anoscope is used. In this procedure, the physician performs a digital vaginal examination and gently tightens the purse-string suture to draw the redundant rectal mucosa into the lumen of the rectum. He inserts an opened stapler through the circular anoscope, passing the anvil through the purse-string suture. The stapler is fired and held closed for one minute to assist hemostasis. The physician opens the stapler head, removing the stapler and circular anoscope together. The surgeon inspects the specimen to verify that a complete circumferential excision of tissue. The physician inserts the anoscope or a retractor into the anus to inspect for bleeding at the staple line. Revisions: For excision of hemorrhoids, see 46250-46262; for destruction, see 46934-46936; for injection, use 46500; for ligation, see 46945 and 46946; and for hemorrhoidectomy, use 46947.

Urology

• 52234 Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; SMALL bladder tumor(s) (0.5 up to 2.0 cm). This code has been editorially revised to clarify that this code is intended to encompass fulguration or resection of small tumors greater than or equal to 0.5cm to those measuring less than 2cm. 52224 now applies to those less than 0.5cm (minor lesions) 52235 refers to lesions between 2cm and 5cm (medium) and 52240 refers to large lesions, over 5cm.

A coding tip: When multiple bladder tumors are fulgurated or resected using a cystourethroscope, the tumor sizes should not be added together for a cumulative total size. Rather, each tumor should be measured individually to determine the appropriate category. These codes should each be reported only once for single or multiple tumors that individually fall into the measurement categories. (Source: October 2002 CPT Assistant newsletter, AMA.)

GYN

• 57267 Insertion of mesh or other prosthesis for repair of pelvic floor defect, each site (anterior, posterior compartment), vaginal approach (List separately in addition to code for primary procedure). This is an added code that lets the surgeon use intervening prosthetic material (such as an autograft, allograft, xenograft of synthetic) if he determines the native tissues too weak for inadequate repair, especially in patients who have undergone previous repair attempts. The physician work involved in inserting prosthetic material, including extra sutures, preparing the prosthesis for insertion (sizing), and ensuring proper placement for repair of pelvic floor defect(s), is distinct from the physician work involved in performing the primary pelvic floor defect repair(s) which primarily involves re-approximation of pelvic fascial tissues only. Therefore, code 57267 should be reported in addition to one of five primary vaginal repair procedures: 45560 Repair of rectocele (separate procedure; 57240 Anterior colporrhaphy, repair of cystocele with or without repair of urethrocele; 57250 Posterior colporrhaphy, repair of rectocele with or without perineorrhaphy; 57260 Combined anteroposterior colporrhaphy; and 57265 Combined anteroposterior colporrhaphy; with enterocele repair.
• 58356 Endometrial cryoablation with ultrasonic guidance, including endometrial curettage, when performed. This added code uses extreme cold and ultrasound (instead of the heat and hysteroscopy of thermal ablation) it doesn't require general anesthesia and so may be performed in the office or outpatient hospital settings. This procedure diagnoses or treats excessive, frequent or irregular menstruation, metrorrhagia and premenopausal menorrhagia. Suction curettage is recommended to thin the endometrial lining before cryotherapy; if curettage is performed, it should not be reported separately. This procedure is contraindicated in patients with active genital infection, active pelvic inflammatory disease, active urinary tract infection or intrauterine device currently in place. Revision: Do not report with 58100, 58120, 58340, 76700 or 76856.
• 58565 Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants. This added procedure is also called Essure; it involves the surgeon placing coils in the fallopian tubes for sterilization. Revisions: Do not report with 58555 or 57800; for unilateral procedure, use modifier 52.

Ophthalmology

• 66710 Ciliary body destruction; cyclophotocoagulation, transscleral. In this new endoscopic technique, the surgeon must make an incision to insert the endoscope through the anterior segment so he can directly visualize the tissue to be coagulated. The new code
• 66711 (Ciliary body destruction; cyclophotocoagulation, endoscopic), which includes the endoscopic approach, differentiates the intraocular cyclophotocoagulation from the extra-ocular procedure described in code 66710, which carries less surgical risk. Neither code is reported with 66990 because the safer endoscopic approach has been included in the procedure.

Combining conscious sedation
See New Appendix G of the CPT 2005 code book for the codes that include conscious sedation as inherent in the procedure. Since the designated services include conscious sedation, it is not appropriate for the same physician to report both the service and one of the conscious sedation codes (99141 or 99142), because CMS expects he is providing both the conscious sedation and the service simultaneously.