Michael Nelson, MD, FCCP

The CHEST Board of Regents (BOR) convened a hybrid meeting in Atlanta prior to the pulmonary board review course. Hopefully, many of you had the opportunity to participate in that excellent learning experience. The function of the BOR is to provide direction and oversight for the organization’s strategy and goals, including the development of the many programs that are so expertly crafted by our talented staff, with contributions from our volunteers. The BOR has adopted organizational goals and metrics around our four key pillars, including: education, people, products, and growth. Our EVP/CEO, Dr. Robert Musacchio, opened the meeting with a review of the organization’s mid-year progress toward achieving these annual goals. Despite the current economic turmoil and need for flexibility in our COVID landscape, CHEST is on track to meet or exceed the majority of the stated goals. The team continues efforts to achieve our key metrics related to increasing learners, members, and growth in revenue – we anticipate the upcoming annual meeting will only bolster our progress.

Every BOR meeting includes a report from the Finance Committee, which is thoroughly reviewed by the BOR. CHEST investments have fared no better than the rest of the country, but our investment advisors assure us that things will improve.

Similar updates were given by the President of the CHEST Foundation, Dr. Ian Nathanson, who noted that the Foundation will be celebrating its 25th anniversary during CHEST 2022. I would like to personally encourage you to donate and make this year the best year of fundraising. We are eager to bolster our community and patients after the long journey through COVID. Every donation enables more investment in creating access to the profession and in piloting programs across our communities that improve access to care. Thank you to those who have already contributed.

The morning session was completed with excellent presentations by the Chief Learning Officer/Education SVP, Richard Schuch and Publisher/Communications SVP, Nicki Augustyn. Rich provided an update on the education strategy and how it will change to keep up with the ever-changing needs of learners. He also made the observation that CHEST cannot do this alone, and partnering with companies to assist in new methods of content delivery will be important for the future of the organization. Nicki presented data regarding the current membership structure, as well as the effect of the pandemic on membership over the last 2 years.

In the afternoon session, the BOR and staff spent over 2 hours on the topic of advocacy. CHEST has become more active in the area of advocacy for both patients and the medical profession, specifically in the areas of pulmonary, critical care, and sleep medicine. The Health Policy and Advocacy Committee (HPAC) currently has workgroups working in five different areas, including: oxygen, pulmonary rehabilitation, coding and billing, noninvasive ventilation, and tobacco and vaping. However, CHEST is often asked to sign on to or support the advocacy efforts of other organizations, including other medical societies, patient groups, and industry groups. At times, the decision to support or not support is easy. While there is a process to make that decision, this session helped better define the process and started to create some norms around when CHEST itself should lead its own statement on a particular issue.

The BOR will meet a total of six times this year, either remotely or in person, to make certain that CHEST continues to fulfill its mission “to champion the prevention, diagnosis, and treatment of chest diseases through education, communication, and research.”

The CHEST Board of Regents (BOR) convened a hybrid meeting in Atlanta prior to the pulmonary board review course. Hopefully, many of you had the opportunity to participate in that excellent learning experience. The function of the BOR is to provide direction and oversight for the organization’s strategy and goals, including the development of the many programs that are so expertly crafted by our talented staff, with contributions from our volunteers. The BOR has adopted organizational goals and metrics around our four key pillars, including: education, people, products, and growth. Our EVP/CEO, Dr. Robert Musacchio, opened the meeting with a review of the organization’s mid-year progress toward achieving these annual goals. Despite the current economic turmoil and need for flexibility in our COVID landscape, CHEST is on track to meet or exceed the majority of the stated goals. The team continues efforts to achieve our key metrics related to increasing learners, members, and growth in revenue – we anticipate the upcoming annual meeting will only bolster our progress.

Every BOR meeting includes a report from the Finance Committee, which is thoroughly reviewed by the BOR. CHEST investments have fared no better than the rest of the country, but our investment advisors assure us that things will improve.

Similar updates were given by the President of the CHEST Foundation, Dr. Ian Nathanson, who noted that the Foundation will be celebrating its 25th anniversary during CHEST 2022. I would like to personally encourage you to donate and make this year the best year of fundraising. We are eager to bolster our community and patients after the long journey through COVID. Every donation enables more investment in creating access to the profession and in piloting programs across our communities that improve access to care. Thank you to those who have already contributed.

The morning session was completed with excellent presentations by the Chief Learning Officer/Education SVP, Richard Schuch and Publisher/Communications SVP, Nicki Augustyn. Rich provided an update on the education strategy and how it will change to keep up with the ever-changing needs of learners. He also made the observation that CHEST cannot do this alone, and partnering with companies to assist in new methods of content delivery will be important for the future of the organization. Nicki presented data regarding the current membership structure, as well as the effect of the pandemic on membership over the last 2 years.

In the afternoon session, the BOR and staff spent over 2 hours on the topic of advocacy. CHEST has become more active in the area of advocacy for both patients and the medical profession, specifically in the areas of pulmonary, critical care, and sleep medicine. The Health Policy and Advocacy Committee (HPAC) currently has workgroups working in five different areas, including: oxygen, pulmonary rehabilitation, coding and billing, noninvasive ventilation, and tobacco and vaping. However, CHEST is often asked to sign on to or support the advocacy efforts of other organizations, including other medical societies, patient groups, and industry groups. At times, the decision to support or not support is easy. While there is a process to make that decision, this session helped better define the process and started to create some norms around when CHEST itself should lead its own statement on a particular issue.

The BOR will meet a total of six times this year, either remotely or in person, to make certain that CHEST continues to fulfill its mission “to champion the prevention, diagnosis, and treatment of chest diseases through education, communication, and research.”

The CHEST Board of Regents (BOR) convened a hybrid meeting in Atlanta prior to the pulmonary board review course. Hopefully, many of you had the opportunity to participate in that excellent learning experience. The function of the BOR is to provide direction and oversight for the organization’s strategy and goals, including the development of the many programs that are so expertly crafted by our talented staff, with contributions from our volunteers. The BOR has adopted organizational goals and metrics around our four key pillars, including: education, people, products, and growth. Our EVP/CEO, Dr. Robert Musacchio, opened the meeting with a review of the organization’s mid-year progress toward achieving these annual goals. Despite the current economic turmoil and need for flexibility in our COVID landscape, CHEST is on track to meet or exceed the majority of the stated goals. The team continues efforts to achieve our key metrics related to increasing learners, members, and growth in revenue – we anticipate the upcoming annual meeting will only bolster our progress.

Every BOR meeting includes a report from the Finance Committee, which is thoroughly reviewed by the BOR. CHEST investments have fared no better than the rest of the country, but our investment advisors assure us that things will improve.

Similar updates were given by the President of the CHEST Foundation, Dr. Ian Nathanson, who noted that the Foundation will be celebrating its 25th anniversary during CHEST 2022. I would like to personally encourage you to donate and make this year the best year of fundraising. We are eager to bolster our community and patients after the long journey through COVID. Every donation enables more investment in creating access to the profession and in piloting programs across our communities that improve access to care. Thank you to those who have already contributed.

The morning session was completed with excellent presentations by the Chief Learning Officer/Education SVP, Richard Schuch and Publisher/Communications SVP, Nicki Augustyn. Rich provided an update on the education strategy and how it will change to keep up with the ever-changing needs of learners. He also made the observation that CHEST cannot do this alone, and partnering with companies to assist in new methods of content delivery will be important for the future of the organization. Nicki presented data regarding the current membership structure, as well as the effect of the pandemic on membership over the last 2 years.

In the afternoon session, the BOR and staff spent over 2 hours on the topic of advocacy. CHEST has become more active in the area of advocacy for both patients and the medical profession, specifically in the areas of pulmonary, critical care, and sleep medicine. The Health Policy and Advocacy Committee (HPAC) currently has workgroups working in five different areas, including: oxygen, pulmonary rehabilitation, coding and billing, noninvasive ventilation, and tobacco and vaping. However, CHEST is often asked to sign on to or support the advocacy efforts of other organizations, including other medical societies, patient groups, and industry groups. At times, the decision to support or not support is easy. While there is a process to make that decision, this session helped better define the process and started to create some norms around when CHEST itself should lead its own statement on a particular issue.

The BOR will meet a total of six times this year, either remotely or in person, to make certain that CHEST continues to fulfill its mission “to champion the prevention, diagnosis, and treatment of chest diseases through education, communication, and research.”

There may be some positive changes coming to evaluation and management (E/M) services effective January 1, 2021. In the proposed calendar year 2020 Physician Fee Schedule (CY 2020 PFS), the Centers for Medicare & Medicaid Services (CMS) suggested a number of coding, payment, and documentation changes for office/outpatient E/M visits, Current Procedural Terminology (CPT^®) codes 99201-99215. A summary of these changes include:

• Separate payment for the five levels of office/outpatient E/M visit CPT codes, as revised by the CPT Editorial Panel effective January 1, 2021. This would include deletion of CPT code 99201 (Level 1 new patient office/outpatient E/M visit) and adoption of the revised CPT code descriptors for CPT codes 99202-99215;

• Elimination of the use of history and/or physical exam to select among code levels;

• Choice of time or medical decision making to decide the level of office/outpatient E/M visit (using the revised CPT interpretive guidelines for medical decision making);

• Payment for prolonged office/outpatient E/M visits using the revised CPT code for such services, including separate payment for new CPT code 99XXX and deletion of Healthcare Common Procedure Coding System (HCPCS) code GPRO1 (extended office/outpatient E/M visit) that was previously finalized for 2021;

• Revise the descriptor for HCPCS code GPC1X and delete HCPCS code GCG0X; and

• Increase in value for HCPCS code GPC1X and allowing it to be reported with all office/outpatient E/M visit levels.

These changes were recommended by CMS to improve payment accuracy, reduce the administrative burden, and better reflect the current practice of medicine. These changes are predicted to result in a simplification of physician documentation and a redistribution of payments favoring providers who deliver primary care or care to more complex patients.


In CY 2019 PFS, CMS proposed to pay a single (blended) rate for office/outpatient visits 2-4, but due to comments from stakeholders, including specialty societies, CMS proposed to accept alternate recommendations by AMA/CPT. These recommendations include using medical decision making or time to determine the level of a visit, rather than the schema that was based on history and physical exam and outlined in the 1995/1997 guidelines. This resulted in elimination of CPT code 99201 and changes to the descriptors of 99202-99215. These codes were resurveyed by the Relative Value Update Committee (RUC) resulting in new values and times. (See Table 1).


One can see that there has been an incremental increase in time and value for most codes. When selecting a code based upon time, there is a range that is defined for each code,and additional information about the codes, including the descriptors and ranges, can be found on the AMA website https://www.ama-assn.org/cpt-evaluation-and-management.

For CPT codes 99205 and 99215 (level 5 codes), an add-on code has also been proposed that would account for additional time spent above the new levels defined in the codes. The descriptor for CPT 99XXX (the final numbers have not yet been assigned) reads Prolonged office or other outpatient evaluation and management service(s) (beyond the total time of the primary procedure which has been selected using total time), requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service; each 15 minutes (List separately in addition to codes 99205, 99215 for office or other outpatient Evaluation and Management services). 99XXX is similar to CPT add-on code 99292 in that it may be used multiple times for a single encounter. This is illustrated in Table 2.


However, 99XXX is only used with level 5 codes. It will replace HCPCS code GPRO1, which had been finalized in the CY 2019 PFS. The proposed code will have a value of 0.61 RVU.


Finally, there is a proposal to revise the descriptor for HCPCS code GPC1X and eliminate HCPCS code GCG0X. The new descriptor for GPC1X Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious, or complex chronic condition. (Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established) is being updated to simplify the coding and, with the elimination of GCG0X, to remove the perception that the code is primary care or specialty specific. The value of GPC1X is also being increased to 0.33 RVU.

It must be made clear that these changes are proposals only, and CMS is still reviewing stakeholder and public comments. Any actual changes will not be codified until publication of the CY2020 PFS later this year. Additional information regarding the proposed rule can be found by accessing https://federalregister.gov/d/2019-16041.

There may be some positive changes coming to evaluation and management (E/M) services effective January 1, 2021. In the proposed calendar year 2020 Physician Fee Schedule (CY 2020 PFS), the Centers for Medicare & Medicaid Services (CMS) suggested a number of coding, payment, and documentation changes for office/outpatient E/M visits, Current Procedural Terminology (CPT^®) codes 99201-99215. A summary of these changes include:

• Separate payment for the five levels of office/outpatient E/M visit CPT codes, as revised by the CPT Editorial Panel effective January 1, 2021. This would include deletion of CPT code 99201 (Level 1 new patient office/outpatient E/M visit) and adoption of the revised CPT code descriptors for CPT codes 99202-99215;

• Elimination of the use of history and/or physical exam to select among code levels;

• Choice of time or medical decision making to decide the level of office/outpatient E/M visit (using the revised CPT interpretive guidelines for medical decision making);

• Payment for prolonged office/outpatient E/M visits using the revised CPT code for such services, including separate payment for new CPT code 99XXX and deletion of Healthcare Common Procedure Coding System (HCPCS) code GPRO1 (extended office/outpatient E/M visit) that was previously finalized for 2021;

• Revise the descriptor for HCPCS code GPC1X and delete HCPCS code GCG0X; and

• Increase in value for HCPCS code GPC1X and allowing it to be reported with all office/outpatient E/M visit levels.

These changes were recommended by CMS to improve payment accuracy, reduce the administrative burden, and better reflect the current practice of medicine. These changes are predicted to result in a simplification of physician documentation and a redistribution of payments favoring providers who deliver primary care or care to more complex patients.


In CY 2019 PFS, CMS proposed to pay a single (blended) rate for office/outpatient visits 2-4, but due to comments from stakeholders, including specialty societies, CMS proposed to accept alternate recommendations by AMA/CPT. These recommendations include using medical decision making or time to determine the level of a visit, rather than the schema that was based on history and physical exam and outlined in the 1995/1997 guidelines. This resulted in elimination of CPT code 99201 and changes to the descriptors of 99202-99215. These codes were resurveyed by the Relative Value Update Committee (RUC) resulting in new values and times. (See Table 1).


One can see that there has been an incremental increase in time and value for most codes. When selecting a code based upon time, there is a range that is defined for each code,and additional information about the codes, including the descriptors and ranges, can be found on the AMA website https://www.ama-assn.org/cpt-evaluation-and-management.

For CPT codes 99205 and 99215 (level 5 codes), an add-on code has also been proposed that would account for additional time spent above the new levels defined in the codes. The descriptor for CPT 99XXX (the final numbers have not yet been assigned) reads Prolonged office or other outpatient evaluation and management service(s) (beyond the total time of the primary procedure which has been selected using total time), requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service; each 15 minutes (List separately in addition to codes 99205, 99215 for office or other outpatient Evaluation and Management services). 99XXX is similar to CPT add-on code 99292 in that it may be used multiple times for a single encounter. This is illustrated in Table 2.


However, 99XXX is only used with level 5 codes. It will replace HCPCS code GPRO1, which had been finalized in the CY 2019 PFS. The proposed code will have a value of 0.61 RVU.


Finally, there is a proposal to revise the descriptor for HCPCS code GPC1X and eliminate HCPCS code GCG0X. The new descriptor for GPC1X Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious, or complex chronic condition. (Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established) is being updated to simplify the coding and, with the elimination of GCG0X, to remove the perception that the code is primary care or specialty specific. The value of GPC1X is also being increased to 0.33 RVU.

It must be made clear that these changes are proposals only, and CMS is still reviewing stakeholder and public comments. Any actual changes will not be codified until publication of the CY2020 PFS later this year. Additional information regarding the proposed rule can be found by accessing https://federalregister.gov/d/2019-16041.

There may be some positive changes coming to evaluation and management (E/M) services effective January 1, 2021. In the proposed calendar year 2020 Physician Fee Schedule (CY 2020 PFS), the Centers for Medicare & Medicaid Services (CMS) suggested a number of coding, payment, and documentation changes for office/outpatient E/M visits, Current Procedural Terminology (CPT^®) codes 99201-99215. A summary of these changes include:

• Separate payment for the five levels of office/outpatient E/M visit CPT codes, as revised by the CPT Editorial Panel effective January 1, 2021. This would include deletion of CPT code 99201 (Level 1 new patient office/outpatient E/M visit) and adoption of the revised CPT code descriptors for CPT codes 99202-99215;

• Elimination of the use of history and/or physical exam to select among code levels;

• Choice of time or medical decision making to decide the level of office/outpatient E/M visit (using the revised CPT interpretive guidelines for medical decision making);

• Payment for prolonged office/outpatient E/M visits using the revised CPT code for such services, including separate payment for new CPT code 99XXX and deletion of Healthcare Common Procedure Coding System (HCPCS) code GPRO1 (extended office/outpatient E/M visit) that was previously finalized for 2021;

• Revise the descriptor for HCPCS code GPC1X and delete HCPCS code GCG0X; and

• Increase in value for HCPCS code GPC1X and allowing it to be reported with all office/outpatient E/M visit levels.

These changes were recommended by CMS to improve payment accuracy, reduce the administrative burden, and better reflect the current practice of medicine. These changes are predicted to result in a simplification of physician documentation and a redistribution of payments favoring providers who deliver primary care or care to more complex patients.


In CY 2019 PFS, CMS proposed to pay a single (blended) rate for office/outpatient visits 2-4, but due to comments from stakeholders, including specialty societies, CMS proposed to accept alternate recommendations by AMA/CPT. These recommendations include using medical decision making or time to determine the level of a visit, rather than the schema that was based on history and physical exam and outlined in the 1995/1997 guidelines. This resulted in elimination of CPT code 99201 and changes to the descriptors of 99202-99215. These codes were resurveyed by the Relative Value Update Committee (RUC) resulting in new values and times. (See Table 1).


One can see that there has been an incremental increase in time and value for most codes. When selecting a code based upon time, there is a range that is defined for each code,and additional information about the codes, including the descriptors and ranges, can be found on the AMA website https://www.ama-assn.org/cpt-evaluation-and-management.

For CPT codes 99205 and 99215 (level 5 codes), an add-on code has also been proposed that would account for additional time spent above the new levels defined in the codes. The descriptor for CPT 99XXX (the final numbers have not yet been assigned) reads Prolonged office or other outpatient evaluation and management service(s) (beyond the total time of the primary procedure which has been selected using total time), requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service; each 15 minutes (List separately in addition to codes 99205, 99215 for office or other outpatient Evaluation and Management services). 99XXX is similar to CPT add-on code 99292 in that it may be used multiple times for a single encounter. This is illustrated in Table 2.


However, 99XXX is only used with level 5 codes. It will replace HCPCS code GPRO1, which had been finalized in the CY 2019 PFS. The proposed code will have a value of 0.61 RVU.


Finally, there is a proposal to revise the descriptor for HCPCS code GPC1X and eliminate HCPCS code GCG0X. The new descriptor for GPC1X Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious, or complex chronic condition. (Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established) is being updated to simplify the coding and, with the elimination of GCG0X, to remove the perception that the code is primary care or specialty specific. The value of GPC1X is also being increased to 0.33 RVU.

It must be made clear that these changes are proposals only, and CMS is still reviewing stakeholder and public comments. Any actual changes will not be codified until publication of the CY2020 PFS later this year. Additional information regarding the proposed rule can be found by accessing https://federalregister.gov/d/2019-16041.

A major change in coding for bronchoscopy occurred on January 1, 2017, as moderate (conscious) sedation is now separately identified from the work relative value units (wRVUs) for the bronchoscopy codes. While traditionally the bronchoscopist provided moderate sedation, in recent clinical practice, other individuals often provide the sedation. CMS mandated refinement of separate Current Procedural Terminology (CPT®) codes to account for the work of moderate procedural sedation. In the final rule published in November 2016, CMS removed 0.25 wRVUs from many of the bronchoscopy codes to account for the work of moderate sedation. To be reimbursed appropriately, include a moderate sedation CPT code with all bronchoscopy procedures.

Use codes 99151 and 99155 for patients younger than 5 years. For a patient 5 years or older, when the bronchoscopist provides moderate sedation, report code 99152 for the initial 15 minutes and 99153 for subsequent time in 15-minute increments. For a patient 5 years or older, when a provider other than the bronchoscopist provides moderate sedation, use code 99156 for the initial 15 minutes and 99157 for subsequent time in 15-minute increments. Utilize codes 99156 and 99157 only when a second provider (other than the bronchoscopist) performs moderate sedation in the facility setting (eg, hospital, outpatient hospital/ambulatory surgery center, skilled nursing facility). When the second provider performs these services in the nonfacility setting (eg, physician office, freestanding imaging center), do not report codes 99155, 99156, or 99157. Moderate sedation does not include minimal sedation (anxiolysis), deep sedation, or monitored anesthesia care (00100-01999).

Do not use a moderate sedation code (99151-2 or 99155-6) if providing less than 10 minutes of moderate sedation. As with other time-based codes, use the subsequent codes 99153 and 99157 when moderate sedation lasts 8 minutes or longer than the initial 15 minutes. The time for moderate sedation begins with the administration of the sedating agent and concludes when the continuous face-to-face presence of the bronchoscopist ends after completion of the procedure. Intermittent, re-evaluation of the patient afterward is postservice work and is not included in the time for moderate sedation. For example, if the bronchoscopist provides moderate sedation for 25 minutes in a 65-year-old man, report 99152 (for the initial 15 minutes) and 99153 (for the subsequent 10 minutes). If an individual other than the bronchoscopist provides moderate sedation for 41 minutes in a 57-year-old woman, use 99156 (for the initial 15 minutes) and two units of 99157 (for the subsequent 26 minutes). If a bronchoscopist provides moderate sedation and reports the appropriate codes after January 1, the 0.25 wRVU change will have no financial impact compared with 2016. If a second provider performs the moderate sedation, expect an approximately $8.72 drop in reimbursement per procedure.

A major change in coding for bronchoscopy occurred on January 1, 2017, as moderate (conscious) sedation is now separately identified from the work relative value units (wRVUs) for the bronchoscopy codes. While traditionally the bronchoscopist provided moderate sedation, in recent clinical practice, other individuals often provide the sedation. CMS mandated refinement of separate Current Procedural Terminology (CPT®) codes to account for the work of moderate procedural sedation. In the final rule published in November 2016, CMS removed 0.25 wRVUs from many of the bronchoscopy codes to account for the work of moderate sedation. To be reimbursed appropriately, include a moderate sedation CPT code with all bronchoscopy procedures.

Use codes 99151 and 99155 for patients younger than 5 years. For a patient 5 years or older, when the bronchoscopist provides moderate sedation, report code 99152 for the initial 15 minutes and 99153 for subsequent time in 15-minute increments. For a patient 5 years or older, when a provider other than the bronchoscopist provides moderate sedation, use code 99156 for the initial 15 minutes and 99157 for subsequent time in 15-minute increments. Utilize codes 99156 and 99157 only when a second provider (other than the bronchoscopist) performs moderate sedation in the facility setting (eg, hospital, outpatient hospital/ambulatory surgery center, skilled nursing facility). When the second provider performs these services in the nonfacility setting (eg, physician office, freestanding imaging center), do not report codes 99155, 99156, or 99157. Moderate sedation does not include minimal sedation (anxiolysis), deep sedation, or monitored anesthesia care (00100-01999).

Do not use a moderate sedation code (99151-2 or 99155-6) if providing less than 10 minutes of moderate sedation. As with other time-based codes, use the subsequent codes 99153 and 99157 when moderate sedation lasts 8 minutes or longer than the initial 15 minutes. The time for moderate sedation begins with the administration of the sedating agent and concludes when the continuous face-to-face presence of the bronchoscopist ends after completion of the procedure. Intermittent, re-evaluation of the patient afterward is postservice work and is not included in the time for moderate sedation. For example, if the bronchoscopist provides moderate sedation for 25 minutes in a 65-year-old man, report 99152 (for the initial 15 minutes) and 99153 (for the subsequent 10 minutes). If an individual other than the bronchoscopist provides moderate sedation for 41 minutes in a 57-year-old woman, use 99156 (for the initial 15 minutes) and two units of 99157 (for the subsequent 26 minutes). If a bronchoscopist provides moderate sedation and reports the appropriate codes after January 1, the 0.25 wRVU change will have no financial impact compared with 2016. If a second provider performs the moderate sedation, expect an approximately $8.72 drop in reimbursement per procedure.

A major change in coding for bronchoscopy occurred on January 1, 2017, as moderate (conscious) sedation is now separately identified from the work relative value units (wRVUs) for the bronchoscopy codes. While traditionally the bronchoscopist provided moderate sedation, in recent clinical practice, other individuals often provide the sedation. CMS mandated refinement of separate Current Procedural Terminology (CPT®) codes to account for the work of moderate procedural sedation. In the final rule published in November 2016, CMS removed 0.25 wRVUs from many of the bronchoscopy codes to account for the work of moderate sedation. To be reimbursed appropriately, include a moderate sedation CPT code with all bronchoscopy procedures.

Use codes 99151 and 99155 for patients younger than 5 years. For a patient 5 years or older, when the bronchoscopist provides moderate sedation, report code 99152 for the initial 15 minutes and 99153 for subsequent time in 15-minute increments. For a patient 5 years or older, when a provider other than the bronchoscopist provides moderate sedation, use code 99156 for the initial 15 minutes and 99157 for subsequent time in 15-minute increments. Utilize codes 99156 and 99157 only when a second provider (other than the bronchoscopist) performs moderate sedation in the facility setting (eg, hospital, outpatient hospital/ambulatory surgery center, skilled nursing facility). When the second provider performs these services in the nonfacility setting (eg, physician office, freestanding imaging center), do not report codes 99155, 99156, or 99157. Moderate sedation does not include minimal sedation (anxiolysis), deep sedation, or monitored anesthesia care (00100-01999).

Do not use a moderate sedation code (99151-2 or 99155-6) if providing less than 10 minutes of moderate sedation. As with other time-based codes, use the subsequent codes 99153 and 99157 when moderate sedation lasts 8 minutes or longer than the initial 15 minutes. The time for moderate sedation begins with the administration of the sedating agent and concludes when the continuous face-to-face presence of the bronchoscopist ends after completion of the procedure. Intermittent, re-evaluation of the patient afterward is postservice work and is not included in the time for moderate sedation. For example, if the bronchoscopist provides moderate sedation for 25 minutes in a 65-year-old man, report 99152 (for the initial 15 minutes) and 99153 (for the subsequent 10 minutes). If an individual other than the bronchoscopist provides moderate sedation for 41 minutes in a 57-year-old woman, use 99156 (for the initial 15 minutes) and two units of 99157 (for the subsequent 26 minutes). If a bronchoscopist provides moderate sedation and reports the appropriate codes after January 1, the 0.25 wRVU change will have no financial impact compared with 2016. If a second provider performs the moderate sedation, expect an approximately $8.72 drop in reimbursement per procedure.

CHEST Physician Editorial Board Member

Confusion in EBUS Coding

There has been some confusion about appropriate coding using the new endobronchial ultrasound codes with some of the other bronchoscopy codes. Notably, when CPT code 31629 bronchoscopy with transbronchial needle aspiration biopsy(s), trachea, main stem and/or lobar bronchus(i) is appropriate to use with code 31652 with endobronchial ultrasound (EBUS) guided transtracheal and/or transbronchial sampling (e.g., aspiration[s]/biopsy[ies]), one or two mediastinal and/or hilar lymph node stations or structures and code 31653 with endobronchial ultrasound (EBUS) guided transtracheal and/or transbronchial sampling (e.g., aspiration[s]/biopsy[ies]), 3 or more mediastinal and/or hilar lymph node stations or structures. Both 31652 and 31653 include needle sampling as a part of the work and therefore, if the bronchoscopy involves only one these procedures, it would be inappropriate to include 31629.

However, mediastinal sampling is often done in conjunction with evaluation of a more peripheral lesion. If a bronchoscopy is performed with needle biopsy(ies) of a peripheral lesion and subsequently an EBUS scope is used to sample mediastinal or hilar lymph node stations, one could utilize 31629 and either 31652 or 31653. As an illustrative example, a 75-year-old man is found to have a 2-cm peripheral nodule in the anterior segment of the right-upper lobe with enlarged right hilar and subcarinal lymph nodes on CT scan. Bronchoscopy is performed, and, initially, the patient has a survey bronchoscopy using a non-EBUS scope, and no lesion is visible. A radial ultrasound probe is used to help identify the peripheral lesion, and multiple needle biopsies are performed as are brushings and washings. Subsequently, an EBUS scope is introduced, and right hilar, right paratracheal, and subcarinal needle biopsies were performed. The appropriate codes to utilize to describe the work done in this procedure include 31623, 31629, 31653, and 31654. Had no peripheral needle biopsies been performed, then code 31629 would NOT be used. Hopefully, this clarifies the issue further.

CMS Ceases Use of HCPCS G Codes for Smoking Cessation

Effective on or after October 1, the Centers for Medicare & Medicaid Services (CMS) will no longer allow use of Healthcare Common Procedural Coding System (HCPCS) codes G0436 (Smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate, greater than 3 minutes, up to 10 minutes) and G0437 (Smoking and tobacco cessation counseling visit for the asymptomatic patient; intensive, greater than 10 minutes). Instead, CMS will utilize the new codes developed for the Current Procedural Terminology (CPT) code set.

CMS has advised its Medicare contractors to replace code G0436 with CPT code 99406 (Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes) and code G0437 with CPT code 99407 (Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes). According to the Medicare National Coverage Determination Manual, tobacco cessation counseling is covered both for symptomatic and asymptomatic smokers. CMS will allow health-care providers two attempts per 12 months to encourage Medicare patients to cease tobacco use but does not define an attempt. Rather, either of the codes may be used up to four times per attempt; so 99406 and 99407 or a combination of these codes may be used up to 8 times in a 12-month period. These codes may be used either as a stand-alone or with an evaluation and management (E&M) service with appropriate documentation. Remember, however, if one uses these codes during an E&M visit, a 25 modifier will need to be appended to the E&M code.
 

CHEST Physician Editorial Board Member

Confusion in EBUS Coding

There has been some confusion about appropriate coding using the new endobronchial ultrasound codes with some of the other bronchoscopy codes. Notably, when CPT code 31629 bronchoscopy with transbronchial needle aspiration biopsy(s), trachea, main stem and/or lobar bronchus(i) is appropriate to use with code 31652 with endobronchial ultrasound (EBUS) guided transtracheal and/or transbronchial sampling (e.g., aspiration[s]/biopsy[ies]), one or two mediastinal and/or hilar lymph node stations or structures and code 31653 with endobronchial ultrasound (EBUS) guided transtracheal and/or transbronchial sampling (e.g., aspiration[s]/biopsy[ies]), 3 or more mediastinal and/or hilar lymph node stations or structures. Both 31652 and 31653 include needle sampling as a part of the work and therefore, if the bronchoscopy involves only one these procedures, it would be inappropriate to include 31629.

However, mediastinal sampling is often done in conjunction with evaluation of a more peripheral lesion. If a bronchoscopy is performed with needle biopsy(ies) of a peripheral lesion and subsequently an EBUS scope is used to sample mediastinal or hilar lymph node stations, one could utilize 31629 and either 31652 or 31653. As an illustrative example, a 75-year-old man is found to have a 2-cm peripheral nodule in the anterior segment of the right-upper lobe with enlarged right hilar and subcarinal lymph nodes on CT scan. Bronchoscopy is performed, and, initially, the patient has a survey bronchoscopy using a non-EBUS scope, and no lesion is visible. A radial ultrasound probe is used to help identify the peripheral lesion, and multiple needle biopsies are performed as are brushings and washings. Subsequently, an EBUS scope is introduced, and right hilar, right paratracheal, and subcarinal needle biopsies were performed. The appropriate codes to utilize to describe the work done in this procedure include 31623, 31629, 31653, and 31654. Had no peripheral needle biopsies been performed, then code 31629 would NOT be used. Hopefully, this clarifies the issue further.

CMS Ceases Use of HCPCS G Codes for Smoking Cessation

Effective on or after October 1, the Centers for Medicare & Medicaid Services (CMS) will no longer allow use of Healthcare Common Procedural Coding System (HCPCS) codes G0436 (Smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate, greater than 3 minutes, up to 10 minutes) and G0437 (Smoking and tobacco cessation counseling visit for the asymptomatic patient; intensive, greater than 10 minutes). Instead, CMS will utilize the new codes developed for the Current Procedural Terminology (CPT) code set.

CMS has advised its Medicare contractors to replace code G0436 with CPT code 99406 (Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes) and code G0437 with CPT code 99407 (Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes). According to the Medicare National Coverage Determination Manual, tobacco cessation counseling is covered both for symptomatic and asymptomatic smokers. CMS will allow health-care providers two attempts per 12 months to encourage Medicare patients to cease tobacco use but does not define an attempt. Rather, either of the codes may be used up to four times per attempt; so 99406 and 99407 or a combination of these codes may be used up to 8 times in a 12-month period. These codes may be used either as a stand-alone or with an evaluation and management (E&M) service with appropriate documentation. Remember, however, if one uses these codes during an E&M visit, a 25 modifier will need to be appended to the E&M code.
 

CHEST Physician Editorial Board Member

Confusion in EBUS Coding

There has been some confusion about appropriate coding using the new endobronchial ultrasound codes with some of the other bronchoscopy codes. Notably, when CPT code 31629 bronchoscopy with transbronchial needle aspiration biopsy(s), trachea, main stem and/or lobar bronchus(i) is appropriate to use with code 31652 with endobronchial ultrasound (EBUS) guided transtracheal and/or transbronchial sampling (e.g., aspiration[s]/biopsy[ies]), one or two mediastinal and/or hilar lymph node stations or structures and code 31653 with endobronchial ultrasound (EBUS) guided transtracheal and/or transbronchial sampling (e.g., aspiration[s]/biopsy[ies]), 3 or more mediastinal and/or hilar lymph node stations or structures. Both 31652 and 31653 include needle sampling as a part of the work and therefore, if the bronchoscopy involves only one these procedures, it would be inappropriate to include 31629.

However, mediastinal sampling is often done in conjunction with evaluation of a more peripheral lesion. If a bronchoscopy is performed with needle biopsy(ies) of a peripheral lesion and subsequently an EBUS scope is used to sample mediastinal or hilar lymph node stations, one could utilize 31629 and either 31652 or 31653. As an illustrative example, a 75-year-old man is found to have a 2-cm peripheral nodule in the anterior segment of the right-upper lobe with enlarged right hilar and subcarinal lymph nodes on CT scan. Bronchoscopy is performed, and, initially, the patient has a survey bronchoscopy using a non-EBUS scope, and no lesion is visible. A radial ultrasound probe is used to help identify the peripheral lesion, and multiple needle biopsies are performed as are brushings and washings. Subsequently, an EBUS scope is introduced, and right hilar, right paratracheal, and subcarinal needle biopsies were performed. The appropriate codes to utilize to describe the work done in this procedure include 31623, 31629, 31653, and 31654. Had no peripheral needle biopsies been performed, then code 31629 would NOT be used. Hopefully, this clarifies the issue further.

CMS Ceases Use of HCPCS G Codes for Smoking Cessation

Effective on or after October 1, the Centers for Medicare & Medicaid Services (CMS) will no longer allow use of Healthcare Common Procedural Coding System (HCPCS) codes G0436 (Smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate, greater than 3 minutes, up to 10 minutes) and G0437 (Smoking and tobacco cessation counseling visit for the asymptomatic patient; intensive, greater than 10 minutes). Instead, CMS will utilize the new codes developed for the Current Procedural Terminology (CPT) code set.

CMS has advised its Medicare contractors to replace code G0436 with CPT code 99406 (Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes) and code G0437 with CPT code 99407 (Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes). According to the Medicare National Coverage Determination Manual, tobacco cessation counseling is covered both for symptomatic and asymptomatic smokers. CMS will allow health-care providers two attempts per 12 months to encourage Medicare patients to cease tobacco use but does not define an attempt. Rather, either of the codes may be used up to four times per attempt; so 99406 and 99407 or a combination of these codes may be used up to 8 times in a 12-month period. These codes may be used either as a stand-alone or with an evaluation and management (E&M) service with appropriate documentation. Remember, however, if one uses these codes during an E&M visit, a 25 modifier will need to be appended to the E&M code.