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Volume 19 Bulletin 2 / 2009

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Your practical guide to current coding

BULLETIN 2009

AMA Healthier Life StepsTM: Coding for Routine Adult Lifestyle Screening, Early Intervention, and Motivational Interviewing

The AMA Healthier Life StepsTM program provides tools for making changes in an integrated fashion through a physicianpatient alliance for a longer and healthier life addressing: · Diet; · Physical activity; · Alcohol consumption; and · Tobacco use. Physicians can make a difference by playing a key role in promoting health behaviors that can improve patients' lives by: · Briefly screening patients for key health behaviors; · Reminding them of the important issues surrounding these behaviors; and · Encouraging them to make lifestyle changes and building their confidence to do so. Two thirds of Americans die from on, of the following diseases: heart disease (652,000 deaths), cancer (559,000), stroke/cerebrovascular diseases (144,00), chronic lower respiratory diseases (130,933), accidents/unintentional injuries (118,000), and diabetes (75,000). Many of these deaths are premature; ie, occurring before age 75 years, and in many cases, before age 65 years, with a cost to our society of almost $800 billion annually. Underlying these diseases are unhealthy but potentially preventable behaviors: (1) unhealthy nutrition (diets characterized by high intake of sodium, saturated and trans fats, and/or calories and low intake of fruits and vegetables); (2) physical inactivity; (3) smoking; and (4) excess or risky alcohol consumption. The vast majority of our population engages in at least one of these unhealthy lifestyle behaviors and many engage in all four. Although physicians devote considerable time to treating these risk factors pharmacologically, lifestyle counseling is the first recommended step of therapy in national guidelines. Modification of lifestyle is also the recommended cornerstone of preventing the development of these risk factors.

Preventive Counseling

Behavioral health basic screening, assessment, and early intervention services have grown in availability and sophistication. These services may be freestanding, utilized within health care settings, with availability designed for either the general public or only to subscribers, or through individual health care systems and other institutions (public schools, higher education, worksites, and employee assistance services). Their use may be initiated by patients, prompted by physicians and other health care providers, as part of health care or public health/prevention services through an array of delivery instruments, such as telephone services, the Internet, CD-Rom, office-based, and other electronic instruments. Incorporated into medical practice, they can assist in the provision of services while improving the quality control and level of interaction with patients.

E/M--Preventive Medicine Services

The "comprehensive" nature of the Preventive Medicine Services codes 99381-99397 reflects an age and gender appropriate history/exam and is not synonymous with the "comprehensive" examination required in the evolution and management (E/M) codes 99201-99350. Codes 99381-99397 include counseling/anticipatory guidance/risk factor reduction interventions provided at the time of the initial comprehensive preventive medicine examination or periodic re-evaluation. (Codes 99401-99412 are used for reporting counseling/anticipatory guidance/risk factor reduction interventions provided separately from the preventive medicine examination.) If an E/M service code (99201-99350) is reported in addition to a code from the 99381-99397 and/or 99401-99412 series, modifier 25, Significant, separately identifiable E/M by the same physician on the same day of the procedure or other service, should be appended to the appropriate level E/M service code. Modifier 25 is reported to indicate that on the day a procedure or service identified by a CPT code was performed, the patient's condition required a significant and separately identifiable E/M service above and beyond the other service provided. A significant, separately identifiable E/M service is defined and/or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported.

Screening and Brief Intervention (SBI)

Many physicians ask patients about their alcohol or drug use as part of a comprehensive medical history in the context of a periodic, scheduled, preventive care office visit, or in more acute care settings. When the patient's health or presenting medical condition is considered jeopardized by alcohol or drug consumption, physicians typically provide general advice to reduce or stop use and, in certain cases, recommend specialty substance abuse treatment or community mutual-help groups such as Alcoholic Anonymous (AA) or Narcotic Anonymous (NA). Such interactions are most appropriately reported using existing CPT codes. Specific, evidence-based verbal, written, or electronic screening questionnaires to detect alcohol and drug problems are used by a large number of physicians and other licensed health care professionals in diverse clinical settings. A positive screen is immediately followed by a content specific "brief intervention," which is designed to increase the probability that a patient with a positive screen will reduce his or her alcohol intake, abstain from substance use, and address substance-related problems. A screening brief intervention (SBI) describes a different type of patient-professional interaction. It requires a significant amount of time and additional acquired skills, beyond that required for provision of general advice. SBI techniques are discrete, clearly distinguishable clinical procedures that are effective in identifying problematic alcohol or substance use.

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Preventive Medicine, Individual or Group Counseling

Preventive medicine individual or group counseling codes, 99401-99404, 99411 and 99412 describe preventive medicine individual or group counseling services. The CPT guidelines indicate the use of these codes for face-to-face visits provided by a physician or other qualified health care professional "promoting health and preventing illness or injury. They are distinct from E/M services that may be reported separately when performed. Risk factor reduction services are used for persons without a specific illness for which the counseling might otherwise be used as part of treatment. Preventive medicine counseling and risk factor reduction interventions will vary with age and should address such issues as family problems, diet and exercise, substance abuse, sexual practices, injury prevention, smoking cessation, dental health, and diagnostic and laboratory test results available at the time of the encounter."

Behavior Change Interventions, Individual

As indicated in the guidelines for codes 99406-99409, behavior change interventions are performed "for persons who have a behavior that is often considered an illness in itself, such as tobacco use and addiction, substance abuse/misuse; or obesity. Behavior change services may be reported when performed as part of the treatment of the conditions(s) related to or potentially exacerbated by the behavior or when performed to change the harmful behavior that has not yet resulted in an illness. Any E/M services reported on the same day must be distinct, and time spent providing these services may not be used as a basis for the E/M code selection. Behavior change services involve specific validated interventions of assessing readiness for change and barriers to change, advising a change in behavior, assisting by providing specific suggested actions and motivational counseling, and arranging for services and follow-up."

Coding Tip

For counseling groups of patients with symptoms or established illness, use code 99078, Physician educational services rendered to patients in a group setting (eg, prenatal, obesity, or diabetic instructions).

Coding Tip

The Health and Behavior Assessment/Intervention services codes, 96150-96155 should not be reported on the same day as codes 99406-99409.

CPT® Assistant Bulletin / Volume 19 Issue 2 · 2009

Coding for Health Behavior Screening and Counseling

The AMA and other organizations are committed to actively advocating for and expanding physician compensation for health behavior counseling. At the present time a number of existing coding options are available to be utilized. There are CPT® codes for tobacco (99406, 99407) and alcohol (99408, 99409) counseling, and for diet change and prevention (99401-99404, 99411-99413). The Preventive Medicine Services subsection subheading in the CPT codebook, Counseling Risk Factor Reduction and Behavior Change Intervention, includes codes for reporting tobacco use cessation counseling, and alcohol and/or drug-related screening and brief intervention for new or established patients. Because tobacco-use cessation counseling services and alcohol and/or drug-related screening and brief intervention are distinct services, they can be separately reported in addition to an evaluation and management (E/M) service. The Counseling Risk Factor Reduction and Behavior Change Intervention guidelines further describe these services and provide instructions on how to report behavior change intervention services involving validated interventions. The use of standardized evidence-based screening instruments and tools with reliable documentation and appropriate sensitivity is required, in order to separately report for these services. A CPT code for physical activity counseling is not yet available. However, these screening and counseling services may be reported as part of an extended visit for chronic disease management when significant counseling time is needed (eg, for diabetes). The Centers for Medicare & Medicaid Services (CMS) has several codes that may be used for services to patients covered by Medicare and Medicaid (although states vary on their Medicaid coverage). In addition, CPT coding guidelines may differ from thirdparty payer guidelines. Eligibility for payment, as well as coverage policy, is determined by each individual insurer or third-party payer. For reimbursement or third-party payer policy issues, please contact your local third-party payer. Physicians may utilize opportunities to introduce preventive counseling as components of early interventions for the diseases these unhealthy lifestyle behaviors give rise to, and as a strategy to prevent the full development of these diseases with the associated complications. For example, the appearance of precursors for diabetes and cardiovascular diseases are opportunities to counsel patients on diet, exercise, smoking, and excessive alcohol use. Patients are more likely to be receptive to discuss their behaviors in the context of preventing illness or reducing their risks for illness (especially when warning signs and initial symptoms arise) when both physicians and patients are concerned about these problems. For example, conditions such as lower back pain (eg, related to obesity), signs of metabolic syndrome, osteoporosis, hypertension, erectile dysfunction,

obesity, family histories of cancer, alcoholism, and heart disease are all opportunities to prompt discussion of one or more of the key four unhealthy lifestyle behaviors: diet, physical activity, alcohol consumption and tobacco use.

Other Reportable Services

If a patient requires other types of therapeutic, preventive, and/or other interventions, these procedures or services may also be reported. This includes the services of the many health care professionals and support staff that play an important role in primary prevention and disease treatments. Prevention and risk factor reduction is the ultimate team sport as it is well established that physician recommendations can motivate patients and other professionals can most effectively provide the education and more intensive interventions to reach success. Examples of additional codes that may also be reported are codes describing other preventive medicine services (code 99420), physical medicine and rehabilitation therapeutic procedures (code 97000 series) and cardiovascular rehabilitation (codes 93797, 93798, 93668) for those who require rehabilitation to increase physical activity. Dietary counseling and medical nutrition therapy (codes 9780297804) and patient self-management and education (codes 98960-98962) are important in treating many diseases related to these risk factors and in reducing the risk factors themselves. In addition to the tobacco cessation, and alcohol/drug screening and brief intervention, the Health and Behavior Assessment/Intervention services (codes 96150-96155) may be used by nonphysicians to report the types of assessment and motivational interviewing inherent in changing behaviors that adversely impact medical conditions. Category II codes may be used to report many activities that are described in performance measures (see the following AMA activities that promote prevention and quality improvement in this area). Other miscellaneous services having relevance for preventive services, include services for educational supplies and materials (code 99071).

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Physician Consortium for Performance Improvement® (PCPI)--Alcohol Use

Since 2004, the Unites States Preventive Services Task Force (USPSTF) has strongly recommended screening and behavioral counseling interventions to reduce alcohol misuse by adults, including pregnant women, in primary care settings. During new patient encounters and at least annually, patients in general and mental healthcare settings should be screened for at-risk drinking, alcohol use problems and illnesses, and any tobacco use. All patients identified with alcohol use in excess of National Institute on Alcohol Abuse and Alcoholism guidelines and/or any tobacco use should receive brief motivational counseling intervention by a healthcare worker trained in this technique."

CPT® Assistant Bulletin / Volume 19 Issue 2 · 2009

The Physician Consortium for Performance Improvement® (PCPI) approved Preventive Care & Screening Physician Performance Measurement Set: Measure #2: Unhealthy Alcohol Use: Screening, in September 2008. These measures are described for performance in the primary care and ambulatory care settings. For complete descriptions, background, technical information, citations and other details on this measure go to www.ama-assn.org/ama1/pub/upload/ mm/370/pcs_final08.pdf.

and providing social support within and outside of treatment. Common practices that complement this framework include motivational interviewing, the 5-R's used to treat tobacco use (relevance, risks, rewards, roadblocks, repetition), assessing readiness to change, and more intensive counseling and/or referrals for quitters needing extra help. Telephone "quit lines" have also been found to be an effective adjunct to counseling or medical therapy. · Clinics that implement screening systems designed to regularly identify and document a patient's tobacco use status increased their rates of clinician intervention. The Physician Consortium for Performance Improvement® (PCPI) approved Preventive Care & Screening Physician Performance Measurement Set: Measure #1: Tobacco Use: Screening & Cessation Intervention in September 2008. For complete descriptions, background, technical information, citations, and other details on this measure go to www. ama-assn.org/ama1/pub/upload/mm/370/pcs_final08.pdf.

Physician Consortium for Performance Improvement®(PCPI)--Tobacco Use

The USPSTF (2003) strongly recommends that clinicians screen all adults for tobacco use and provide tobacco cessation interventions for those who use tobacco products. All patients should be asked if they use tobacco and should have their tobacco-use status documented on a regular basis. Evidence has shown that clinical screening systems, such as expanding the vital signs to include tobacco status or the use of other reminder systems such as chart stickers or computer prompts, significantly increase rates of clinician intervention. All physicians should strongly advise every patient who smokes to quit because evidence shows that physician advice to quit smoking increases abstinence rates.

Physician Consortium for Performance Improvement®(PCPI)--Diet and Nutrition

The USPSTF recommends intensive behavioral dietary counseling for adult patients with hyperlipidemia and other known risk factors for cardiovascular, and diet-related chronic disease. Intensive counseling can be delivered by primary care clinicians or by referral to other specialists, such as nutritionists or dietitians. Grade: B Recommendation [at least fair evidence that the service improves important health outcomes and concludes that benefits substantially outweigh harms]. The USPSTF concludes that the evidence is insufficient to recommend for or against routine behavioral counseling to promote a healthy diet in unselected patients in primary care settings. Grade: I Statement [evidence that the service is effective is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined]. Some clinical considerations listed by the USPSTF: · Effective interventions combine nutrition education with behaviorally-oriented counseling to help patients acquire the skills, motivation, and support needed to alter their daily eating patterns and food preparation practices. Examples of behavior-oriented counseling interventions include: teaching self monitoring; training to overcome common barriers to selecting a healthy diet; helping patients to set their own goals; providing guidance in shopping and food preparation; role playing; and arranging for intra-treatment social support. In general, these interventions can be described with reference to the 5-A behavioral counseling framework:

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Since even minimal interventions that last less than 3 minutes increase overall tobacco abstinence rates, every tobacco user should be offered an intervention whether or not he or she is referred to an intensive intervention. Some clinical considerations listed by the USPSTF include: · Brief tobacco cessation counseling interventions, including screening, brief counseling (3 minutes or less), and/or pharmacotherapy, have proven to increase tobacco abstinence rates, although there is a dose-response relationship between quit rates and the intensity of counseling. Effective interventions may be delivered by a variety of primary care clinicians. · The 5-A behavioral counseling framework provides a useful strategy for engaging patients in smoking cessation discussions: Ask about tobacco use. Advise to quit through clear personalized messages. Assess willingness to quit. Assist to quit. Arrange follow-up and support. · Helpful aspects of counseling include providing problem-solving guidance for smokers to develop a plan to quit and to overcome common barriers to quitting

CPT® Assistant Bulletin / Volume 19 Issue 2 · 2009

Assess dietary practices and related risk factors. Advise to change dietary practices. Agree on individual diet change goals. Assist to change dietary practices or address motivational barriers. Arrange regular follow-up and support or refer to more intensive behavioral nutritional counseling (eg, medical nutrition therapy) if needed. · Two approaches appear promising for the general population of adult patients in primary care settings: 1. Medium-intensity face-to-face dietary counseling (2 to 3 group or individual sessions) delivered by a dietitian or nutritionist or by a specially trained primary care physician or nurse practitioner. 2. Lower-intensity interventions that involve 5 minutes or less of primary care provider counseling supplemented by patient self-help materials, telephone counseling, or other interactive health communications. · However, more research is needed to assess the longterm efficacy of these treatments and the balance of benefits and harms [in primary care settings]. Regarding recommendations for routine vitamin supplementation to prevent cancer and cardiovascular disease, the USPSTF concludes that the evidence is insufficient to recommend for or against the use of supplements of vitamins A, C, or E; multivitamins with folic acid; or antioxidant combinations for the prevention of cancer or cardiovascular disease. Grade: I Statement [evidence that the service is effective is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined]. The USPSTF recommends against the use of beta-carotene supplements, either alone or in combination, for the prevention of cancer or cardiovascular disease. Grade: D Recommendation [at least fair evidence that the service is ineffective or that harms outweigh benefits].

The USPSTF concludes that the evidence is insufficient to recommend for or against the use of moderate- or low-intensity counseling together with behavioral interventions to promote sustained weight loss in obese adults. Grade: I Statement [evidence that the service is effective is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined]. The USPSTF concludes that the evidence is insufficient to recommend for or against the use of counseling of any intensity and behavioral interventions to promote sustained weight loss in overweight adults. Grade: I Statement [evidence that the service is effective is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined]. Some clinical considerations listed by the USPSTF include: · The most effective interventions combine nutrition education and diet and exercise counseling with behavioral strategies to help patients acquire the skills and supports needed to change eating patterns and to become physically active. The 5-A framework (Assess, Advise, Agree, Assist, and Arrange) has been used in behavioral counseling interventions such as smoking cessation and may be a useful tool to help clinicians guide interventions for weight loss. Initial interventions paired with maintenance interventions help ensure that weight loss will be sustained over time. · It is advisable to refer obese patients to programs that offer intensive counseling and behavioral interventions for optimal weight loss. The USPSTF defined intensity of counseling by the frequency of the intervention. A high-intensity intervention is more than 1 person-toperson (individual or group) session per month for at least the first 3 months of the intervention. A mediumintensity intervention is a monthly intervention, and anything less frequent is a low-intensity intervention. There are limited data on the best place for these interventions to occur and on the composition of the multidisciplinary team that should deliver high-intensity interventions. · A number of techniques, such as bioelectrical impedance, dual-energy x-ray absorptiometry, and total body water can measure body fat, but it is impractical to use them routinely. Calculating a person's body mass index (BMI), which is simply weight adjusted for height, is a more practical and widely-used method to screen for obesity. Increased BMI is associated with increase in adverse health effects. Central adiposity increases the risk for cardiovascular and other diseases independent of obesity. Clinicians may use the waist circumference as a measure of central adiposity. Men with waist circumferences greater than 102 cm (> 40 inches) and women with waist circumferences greater than 88 cm (> 35 inches) are at increased risk for cardiovascular

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Screening for Obesity in Adults

The USPSTF recommends that clinicians screen all adult patients for obesity and offer intensive counseling and behavioral interventions to promote sustained weight loss for obese adults. Grade: B Recommendation [at least fair evidence that the service improves important health outcomes and concludes that benefits substantially outweigh harms].

CPT® Assistant Bulletin / Volume 19 Issue 2 · 2009

disease. The waist circumference thresholds are not reliable for patients with a BMI greater than 35. (USPSTF, 2003) · The USPSTF concluded that the evidence on the effectiveness of interventions with obese people may not be generalizable to adults who are overweight but not obese.

Table 1. Classification of overweight and obesity by BMI** Obesity Class

Underweight Normal Overweight Obesity I II Extreme Obesity III

Some Clinical Considerations listed by the USPSTF include: · Regular physical activity helps prevent cardiovascular disease, hypertension, type 2 diabetes, obesity, and osteoporosis. It may also decrease all-cause morbidity and lengthen life-span. · Benefits of physical activity are seen at even modest levels of activity, such as walking or bicycling 30 minutes per day on most days of the week. Benefits increase with increasing levels of activity. · Whether routine counseling and follow-up by primary care physicians results in increased physical activity among their adult patients is unclear. Existing studies limit the conclusions that can be drawn about efficacy, effectiveness, and feasibility of primary care physical activity counseling. Most studies have tested brief, minimal, and low-intensity primary care interventions, such as 3 to 5 minute counseling sessions in the context of a routine clinical visit. · Multi-component interventions combining provider advice with behavioral interventions to facilitate and reinforce healthy levels of physical activity appear the most promising. Such interventions often include patient goal setting, written exercise prescriptions, individually tailored physical activity regimens, and mailed or telephone follow-up assistance provided by specially trained staff. Linking primary care patients to community-based physical activity and fitness programs may enhance the effectiveness of primary care clinician counseling. · Potential harms of physical activity counseling have not been well defined or studied. They may include muscle and fall-related injuries or cardiovascular events. It is unclear whether more extensive patient screening, certain types of physical activity (e.g., moderate vs. vigorous exercise), more gradual increases in exercise, or more intensive counseling and follow-up monitoring will decrease the likelihood of injuries related to physical activity. Existing studies provide insufficient evidence regarding the potential harms of various activity protocols, such as moderate compared with vigorous exercise.

BMI (kg/m2)

<18 18.5-24.9 25.-29.9 30-34.9 35-39.9 40

**Table found in: Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults ­ The Evidence Report (NHLBI, 1998). Adapted from: Preventing and Managing the Global Epidemic of Obesity: Report of the World Health Organization Consultation of Obesity. WHO, Geneva, June 1997

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The Physician Consortium for Performance Improvement® (PCPI) approved Preventive Care & Screening Physician Performance Measurement Set: Measure #10: Obesity Screening in September 2008. For complete descriptions, background, technical information, citations and other details on this measure go to www.ama-ssn.org/ama1/pub/ upload/mm/370/pcs_final08.pdf.

Behavioral Counseling--Promotion of Physical Activity

The USPSTF concludes that the evidence is insufficient to recommend for or against behavioral counseling in primary care settings to promote physical activity. Grade: I Statement [evidence that the service is effective is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined].

For more information on the AMA Healthier Life StepsTM program, visit www.ama-assn.org/go/healthierlifesteps.

CPT® Assistant Bulletin / Volume 19 Issue 2 · 2009

References

American Journal of Preventive Medicine. Behavioral Counseling in Primary Care to Promote a Healthy Diet. 2003;24(1):93-100. American Medical Association. AMNews, Berry, Emily. "Business: Getting Paid for Prevention." March 24/31, 2008. AMEDNEWS.com. American Medical Association. Physician Consortium for Performance Improvement®. Preventive Care & Screening Physician Performance Measurement Set: Measure #2: Unhealthy Alcohol Use: Screening, September 2008. www.ama-assn.org/ama|pub/ upload/mm/370/pes_final08.pdf. Annals of Internal Medicine. Recommendations for Routine Vitamin Supplementation to prevent Cancer and Cardiovascular Disease. 2003;139:51-5, www.ahrq.gov/clinic/3rduspstf/vitamins/vitaminsrr.htm. Annals of Internal Medicine. Recommendations for Screening for obesity in Adults.2003;139:930-2. www.ahrq.gov/clinic/3rduspstf/ obesity/obesrr.htm. Annals of Internal Medicine. Recommendation of U.S. Preventive Services Task Force. 2002;137:205-7.www.ahrq.gov/clinic/3rduspstf/ physactivity/physactrr.htm. George Washington University Medical Center. Ensuring Solutions (Press Release). "Many Health Plans Will Now Pay for Substance Use Screening and Brief Intervention­All Federal Employees to be Covered." April 17, 2008. www.ensuringsolutions.org/media/ George Washington University Medical Center, Ensuring Solutions, "SBI Reimbursement Guide ­ Everything you Need to Know to Conduct SBI and Get Paid." www.ensuringsolutions.org/media/. National Institute on Alcohol Abuse and Alcoholism, Helping Patients Who Drink Too Much: A Clinician's Guide. http://pubs.niaaa.nih.gov/publications/Practitioner/ CliniciansGuide2005/guide.pdf.

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CPT® Assistant Bulletin / Volume 19 Issue 2 · 2009

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Dan Reyes, Managing Editor Janette Meggs, Contributing Editor Contributing Staff Grace Kotowicz, RN, Julie Watson Contributing Author(s) Richard A. Yoast, MA, PhD, Suzen Moeller, PhD, Division of Medicine and Public Health, AMA Production Staff Chris Meyer, Lisa Chin-Johnson, Mary Ann Albanese, Maria Kowalkowski

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To change address information, please call AMA's Customer Services Department at (800) 621-8335. Notification of change of address must be made at least six weeks in advance. AMA Web site address: www.ama-assn.org Mailing address: CPT Assistant American Medical Association 515 N. State Street Chicago, IL 60654 The CPT Assistant Bulletin information is designed to provide accurate, up-to-date coding information. We continue to make every reasonable effort to ensure the accuracy of the material presented. However, this publication does not replace the CPT codebook; it serves only as a guide. 2009, American Medical Association. All rights reserved. No part of this publication may be reproduced in any form without prior written permission of the publisher. CPT® is a registered trademark of the American Medical Association.

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