Relatively few CPT Code changes for 2008 have impact on emergency medicine. 

Hydration, Injection and Infusion Codes  

One of the changes with a negative impact for EM is the elimination by CPT 2008 of the opportunity for emergency physicians to utilize the “Hydration, Injection and Infusion” codes.  These codes (90760 through 90779) were previously available for use by any physician in any setting.  In the preamble to the description of these codes in the “CPT 2007” code book is the statement “Physician work related to hydration, injection, and infusion services predominantly involves affirmation of treatment plan and direct supervision of staff.”  In CPT 2008 the above portion of the preamble is identical, but now a second sentence has been added, “These codes are not intended to be reported by the physician in the facility setting.” 

The result of this CPT 2008 change is that physicians in “office or clinic settings” may still utilize these codes but physicians in the hospital emergency department are prohibited from using these codes.  ACEP’s representatives at the CPT Editorial Panel and at the RUC strongly protested this change, which now means that certain services, i.e. the hydration, injection and infusion services, may only be reimbursed in “non-facility (hospital) settings.  Relatively little reimbursement is affected by this change, but an unfortunate precedent was established which is directly contradictory to the long held CPT principle that “any code in CPT may be used by any physician as long as the CPT code description of the service provided is applicable”. 

Behavioral intervention  

On page 33 of the CPT 2008 book are new codes for “behavioral intervention”.  These codes apply to “intervention” for an “individual”. 

99406  Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes: 
Work Value = 0.24
Practice Expense Value = 0.08
Professional Liability Value = 0.01 

99406  Intensive, greater than 10 minutes
Work value = 0.50
Practice Expense = 0.13
Practice Expense Value = 0.01 

99408  Alcohol and/or substance (other than alcohol) abuse structured screening (eg AUDIT DAST), and brief intervention (SBI) services, 15 to 30 minutes (minimum 15 minutes)
Work value = 0.65
Practice Expense Value = 0.30
Practice Expense Value = 0.01 

99409  greater than 30 minutes
Work value = 1.30
Practice Expense Value = 0.30
Practice Expense Value = 0.03 

These new codes will likely not have great utility in the Emergency Dept. due to the fact that other hospital personnel (Social Services, Alcohol and Drug Counselors, etc.) may have the time and resources necessary to provide the counseling and intervention described by these codes but in a typical emergency department there is little or no time available for provision of these services. 

New thoracentesis codes: 

The old thoracentesis codes (32000 and 32002) have been replaced by the following new codes: 

32421  Thoracentesis, puncture of the pleural cavity for aspiration, initial or subsequent 

32422  Thoracentesis with insertion of tube, includes water seal (eg for pneumothorax), when performed (separate procedure) 

New chest tube insertion code: 

The old chest tube insertion code of 32020 has been replaced by: 

32551  Tube thoracostomy, includes wqter seal (eg for abscess, hemothorax, empyemal, when performed (separate procedure) 

Other new codes: 

49450  Replacement of gastrostomy or cecostomy (or other colonic) tube, percutaneous, under fluoscopic guidance including contrast injection(s), image documentation and report 

49451  Replacement of duodenostomy or jejujnostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report 

49452  Replacement of gastro-jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report 

Observation Services

One of the major changes impacting emergency physicians in 2008 is the decision by CMS to “bundle” observation services payments for hospitals into the hospitals’ Emergency Department Evaluation and Management code payments.  In other words, if a Medicare patient is seen in the Emergency Dept. and is then admitted to “Observation” rather than an inpatient  bed, there will be no separate payment for the hospital’s “observation services”. The hospital will simply be reimbursed for its emergency department services and the emergency department services reimbursement will be considered to also encompass any “observation services” provided by the hospital.  The clear implication is that hospitals in 2008 will not be eager for emergency physicians to place Medicare patients into “Observation” status since the hospital will not receive  Medicare reimbursement for these services separately, as they have in the past.