New 2023 CPT Coding Changes Impact General Surgery, Related Specialties

The American Medical Association (AMA) Current Procedural Terminology (CPT)* code set is updated annually. This article describes CPT 2023 coding changes that are relevant to general surgery and its related specialties. 

Anterior Abdominal Hernia Repair

Significant coding changes take effect in 2023 for reporting anterior abdominal hernia repair, including: 

• Deletion of codes 49560–49590, which describe open repair of anterior abdominal hernias
• Deletion of codes 49652–49657, which describe laparoscopic repair of anterior abdominal hernias
• Deletion of add-on code 49568, which was reported for implantation of mesh for open ventral/incisional hernias and defects resulting from necrotizing soft tissue infection 
• Twelve new codes (49591–49596 and 49613-49618) to report anterior abdominal hernia repair by any approach (i.e., open, laparoscopic, robotic), further by initial or recurrent hernia, further by total defect size, and further by reducible or incarcerated/strangulated
• Two new codes (49621–49622) to report parastomal hernia repair by any approach (i.e., open, laparoscopic, robotic), further divided by reducible or incarcerated/strangulated
• One new add-on code (49623) for removal of mesh/prosthesis at the time of initial or recurrent anterior abdominal hernia repair or parastomal hernia repair 

Table 1 provides details about code selection. First, determine the total length (size); then choose the type of hernia (initial versus recurrent); and finally, choose the severity (reducible or incarcerated/strangulated). Keep in mind that if there are multiple hernias (i.e., “Swiss cheese”), the entire repair defaults to the highest severity of any of the defects.

These new anterior abdominal hernia repair codes will have a 0-day global assignment. All subsequent procedures and services performed starting the day after the operation need to be separately reported. For example, hospital and office evaluation and management (E/M) visits and suture and/or staple removal should be reported separately. An extensive discussion about these coding changes is available in the November-December 2022 issue of the Bulletin. In addition, a webinar that includes clinical scenarios can be viewed at facs.org/hernia-repair.

Implantation of Mesh for Delayed Closure

Prior to 2023, add-on code 49658 was reported for mesh placement for open hernia repair or for closure of wounds from necrotizing soft tissue infection. This code will be deleted, and mesh placement will be included as inherent for all new anterior abdominal hernia repair codes. The remaining use of code 46958, (closure of wounds from necrotizing soft tissue infection), now will be reported with new code 15778, Implantation of absorbable mesh or other prosthesis for delayed closure of defect(s) (i.e., external genitalia, perineum, abdominal wall) due to soft tissue infection or trauma. Patients with necrotizing soft tissue infections typically result in a large, open wound that cannot be closed primarily. When the infection has resolved, absorbable mesh or other prosthesis is placed to allow healing by secondary intent until such time that a skin graft or skin closure can be accomplished. In contrast to add-on code 49658, new code 15778 has a 0-day global period and may be reported with or without other procedures performed at the same operative session. 

Removal of Sutures and/or Staples “In the Office”

The 0-day global period assigned to the new anterior abdominal hernia repair codes required additional new codes for reporting services performed at postoperative E/M visits. For 2023, two new add-on codes were established for reporting suture and/or staple removal in conjunction with an E/M visit. Code 15853, Removal of sutures or staples not requiring anesthesia (List separately in addition to E/M code), and code 15854, Removal of sutures and staples not requiring anesthesia (List separately in addition to E/M code), may be reported with an appropriate E/M service for any procedure that has a 0-day global period, including the new anterior abdominal hernia repair codes. 

These new add-on suture/staple removal codes do not have physician work relative value units (RVUs) assigned because they are for practice expense reimbursement only (i.e., clinical staff time, disposable supplies, and use of equipment). Prior to 2023, the practice expense was embedded in the payment for the deleted 90-day global hernia repair codes. Keep in mind that these codes may be reported multiple times, but only once per day. For example, on postop day 3 after a 0-day global procedure is performed, code 15853 can be reported for suture removal related to drain removal. Then, on postop day 10, code 15853 can be reported again with an appropriate E/M for staple removal. Because codes 15853 and 15854 are add-on codes to be reported with an E/M code, no modifier should be appended to the E/M code.

Removal of Sutures or Staples “Under Anesthesia”

While reviewing the issue of reporting suture and/or staple removal for codes with a 0-day global period, the ACS CPT advisors discovered unusual reporting of code 15851 that previously described removal of sutures or staples “under anesthesia other than local.” Specifically, more than 80% of the Medicare claims were office-based even though the intent of this code was for reporting a facility-based procedure. The ACS recommended revision of code 15851 to describe suture or staple removal, specifically requiring general anesthesia or moderate sedation (for example, removal of sutures on the face of an infant). For 2023, code 15851, Removal of sutures or staples requiring anesthesia (i.e., general anesthesia, moderate sedation), will be priced only in the facility setting. For suture or staple removal in the office setting, new add-on codes 15853 or 15854 should be reported. In addition, with the revision to code 15851, code 15850, (suture/staple removal “same” physician), was deleted with a parenthetical reference added to report code 15851.

Percutaneous Arteriovenous Fistula

Two new codes have been created to report percutaneous arteriovenous (AV) fistula creation in the upper extremity via a single access of both the peripheral artery and peripheral vein (36836, Percutaneous arteriovenous fistula creation, upper extremity, single access of both the peripheral artery and peripheral vein, including fistula maturation procedures [e.g., transluminal balloon angioplasty, coil embolization] when performed, including all vascular access, imaging guidance and radiologic supervision and interpretation), and via separate access sites of the peripheral artery and peripheral vein (36837, Percutaneous arteriovenous fistula creation, upper extremity, separate access sites of the peripheral artery and peripheral vein, including fistula maturation procedures [e.g., transluminal balloon angioplasty, coil embolization] when performed, including all vascular access, imaging guidance and radiologic supervision and interpretation). Previously, there were only codes for AV fistula creation via an open approach. Please note that percutaneous AV fistula creation in any location other than the upper extremity should be reported with the unlisted vascular surgery procedure code 37799.

Intragastric Bariatric Balloon

Two new endoscopic bariatric treatment codes will be available in 2023 to report esophagogastroduodenoscopy (EGD) deployment and removal of a bariatric balloon device; code 43290, EGD, flexible, transoral; with deployment of intragastric bariatric balloon, and code 43291, EGD, flexible, transoral; with removal of intragastric bariatric balloon(s). 

Delayed Creation Site for Embedded Intraperitoneal Catheter

In the final rule for 2022, the Centers for Medicare & Medicaid Services (CMS) received a public nomination that code 49436, Delayed creation of exit site from embedded subcutaneous segment of intraperitoneal cannula or catheter, can be safely performed in the office setting, but the code was not priced in this setting. CMS agreed that if this service were to be performed in an office, there may be an ease in the burden to the provider and patient, when trying to coordinate access with the current public health emergency facility restricted schedules. Although CPT did not change the code descriptor for 49436, this procedure was reviewed by the American Medical Association/Specialty Society Relative Value Scale Update Committee (AMA/RUC) to add practice expense details for office reimbursement. Beginning in 2023, the nonfacility practice expense RVUs have increased to account for the office clinical staff time, disposable supplies, and use of office equipment.

Modifier 93 Synchronous Audio-Only Telemedicine

Representatives of several state insurance providers, including Medicaid, received approval for the new modifier 93, Synchronous Telemedicine Service Rendered Via Telephone or Other Real-Time Interactive Audio-Only Telecommunications System, which will be appended to select codes to indicate when a service is provided via an audio-only technology (primarily via telephone). This modifier will help third party payers collect data to distinguish service modalities (audio-only, audio-video, traditional face-to-face) and allow for monitoring and evaluation of the frequency of use and clinical efficacy of these delivery methods to inform future policies and payment. In addition to the new modifier, CPT has added the list of applicable codes in the new Appendix T in the codebook. CMS has accepted application of modifier 93 for some telehealth services during the public health emergency (PHE) and for a specified number of days after the PHE ends. The list of Medicare-approved telehealth services can be accessed at: cms.gov/medicare/medicare-general-information/telehealth/telehealth-codes.

E/M Services Guidelines

For 2023, the E/M code families that are based on “levels” (i.e., straightforward, low, moderate, high) were updated to integrate the revisions that were made to the office/outpatient E/M services codes in 2021, and the E/M services guidelines were revised to standardize reporting of all E/M codes. These revised guidelines provide new definitions for problems addressed and expanded guidelines about using time to select a level of service. It is important that surgeons who report E/M services take the time to review the revised E/M services guidelines in the CPT codebook to understand correct reporting of these services beginning in 2023. 

Collapsing of Codes for Inpatient and Observation Care E/M Services

Observation care E/M codes (99217–99220, 99224–99226) have been deleted, and the descriptors for the hospital inpatient E/M codes (99221–99223, 99231–99239) and inpatient consultation codes (99252–99255) have been revised to include observation care services. With the changes from reporting levels of history and exam to performing only medically required history and exam, along with code selection based on medical decision-making or time, there no longer was a need for separate reporting of inpatient and observation care services. 

Keep in mind that although the revised CPT code descriptors state that a medically appropriate history and/or exam will be required, surgeons should be aware of the documentation needed to meet requirements for billing services under the inpatient prospective payment system or documented information in accordance with hospital conditions of participation, which requires completion and documentation of a history and physical exam for each hospital patient within a specified timeframe of admission. A discussion of these coding changes can be found in an article in the October 2022 issue of the Bulletin. 

Prolonged E/M Services 

For 2023, prolonged E/M services codes 99354–99355 have been deleted and replaced with add-on code 99417 to report increments of 15 minutes of “outpatient” E/M prolonged services. Similarly, codes 99356–99357 have been deleted and replaced with add-on code 99418 for additional increments of 15 minutes of “inpatient” prolonged E/M services. These codes are reported with the highest level of code in each family of E/M services when the level of E/M code is reported using total time. However, since the establishment of code 99417 in 2021, CMS has disagreed with the CPT instructions regarding the point in time at which the prolonged codes should apply. Thus, CMS created Healthcare Common Procedure Coding System (HCPCS) Level II codes G2212 and G0316 to be reported instead of CPT Category I codes 99417 and 99418 for prolonged office/outpatient, and inpatient/observation services provided to Medicare patients. Table 2 compares correct reporting of CMS HCPCS codes and CPT Category I codes.

Learn More

The ACS collaborates with KarenZupko & Associates (KZA) on courses that provide the tools necessary to increase revenue and decrease compliance risk. These courses are an opportunity to sharpen your coding skills. You also will be provided online access to the KZA alumni website, where you will find additional resources and frequently asked questions about correct coding. Information about the courses can be accessed at karenzupko.com/general-surgery.

In addition, as part of the College’s ongoing efforts to help members and their practices submit clean claims and receive proper reimbursement, a coding consultation service—the ACS Coding Hotline—has been established for coding and billing questions. ACS members are offered five free consultation units (CUs) per calendar year. One CU is a period of up to 10 minutes of coding services time. Access the ACS Coding Hotline website at prsnetwork.com/acshotline.

Dr. Megan McNally is a surgical oncologist at Saint Luke’s Health System in Kansas City, MO, and assistant clinical professor in the Department of Surgery at the University of Missouri-Kansas City School of Medicine. She also is a member of the ACS General Surgery Coding and Reimbursement Committee and ACS advisor to the AMA CPT Editorial Panel.

*All specific references to CPT codes and descriptions are © 2022 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.