CPT Code Changes for 2025: Updates to Know
Important Updates from Lyric’s Recent Auditing & Logic Webinar
In an era where your organization's payment integrity depends on staying current with medical advances, the 2025 CPT updates reflect unprecedented technological evolution in healthcare procedures. As health plans prepare for these changes, understanding the detailed requirements and implications of new codes becomes essential for maintaining payment accuracy and appropriate coverage policies.
A recent Lyric webinar featuring Senior Medical Directors Dr. Anne Treviño and Dr. Bernard Steinbacher illuminated the most significant CPT changes for 2025. As Dr. Treviño noted, "Not every change that has happened in the CPT manual for 2025 will be reviewed," focusing specifically on Category 1 codes and substantial procedural updates.
Note: Readers who wish to take in all the covered updates should click on the link above, to watch the webinar replay video. The following are portions of the event relating to select CPT changes:
One: Telemedicine Services
The public health emergency catalyzed rapid expansion in telehealth services, requiring new coding solutions for 2025. Dr. Treviño explained that "prior to COVID, telehealth was being provided with specifically Medicare having strict geographic limitations and states having different regulations." The new codes include both audio-visual and audio-only telecommunications options. For synchronous audio-visual services, codes 98000-98003 cover new patients, while 98004-98007 address established patients. Additionally, for new patients services eclipsing 75 minutes and established patient services eclipsing 55 minutes, prolonged services code 99417 should be used.
According to Dr. Treviño, these codes have specific time thresholds that must be met. "For services that don't meet 10 minutes of service... they are typically 5 to 9 minutes, you're going to report 98106." Further, per 98016, "a brief communication technology-based service,” is to be done by a physician or other qualifying health professional who can report an E&M visit only to an established patient and not originating from an E&M service that was provided with the previous seven days or leading to an E&M service in the next 24 hours or soonest available appointment.
However, Dr. Treviño emphasized that these new codes for telemedicine service are invalid for Medicare. In fact, Medicare wants these types of services to be billed with a traditional E&M code, and then add the appropriate point-of-service (POS) code, as well as the correct modifier—either 93 for an audio-only visit or 95 for an audio-video visit.
Two: Innovative Skin Cell Procedures
New skin replacement surgery CPT codes reflect a groundbreaking three-step process. Dr. Treviño detailed the technique: "The difference is that split thickness skin grafting takes both the epidermis and dermis and then applies it onto the wound bed. Whereas the skin cell suspension autograft takes a small sample of skin. It's then processed to have the epidermal and dermal cells extracted with enzymes and then is made into a suspension to be sprayed onto the wound bed."
The codes break down into three distinct categories, relating to skin cell suspension autograft:
Harvesting: 15011 (first 25cm² or less) with add-on code 15012 for each additional 25cm² or part thereof
Preparation: 15013 (first 25cm² or less) with add-on code 15014 for each 25cm² of harvested skin or part thereof
Application: 15015-15016 for trunk/arms/legs, 15017-15018 for face/scalp/sensitive areas
Three: Intra-abdominal Tumor Procedures
A significant update involves codes for intra-abdominal tumors performed through open approaches. As Dr. Treviño explained, "49186 is the excision or destruction intra-abdominal open... with the sum of the maximum length of the tumors or cysts." The
codes (49186-49190) progress by size: "five centimeters or less, 5.1 to 10cm, 10.1 to 20cm, 20.1 to 30cm, or 49190 - greater than 30cm." She emphasized specific requirements for these measurements: "The tumor should be measured in situ before excision or destruction and documented in the operative report, and measurement should only include the tumors or cysts and not the margins themselves."
Four: MRI Safety Protocol Advancement
The introduction of comprehensive MRI safety codes (76014-76019) addresses critical device management needs related to this type of imaging. Dr. Steinbacher explained the urgency: "The magnetism that exists in those rooms [that have an MRI machine] because it's so immense, can actually change the programming of medical devices implanted within patients.”
The codes make important distinctions between technical staff and physician services. Dr. Steinbacher detailed: "76014, that is assessment by trained clinical staff, including identification and verification of implant components from appropriate sources... 76016, that's MRI safety determination by a physician or other qualified health professional responsible for the safety of the MR procedure, including review of the implant MR Conditions for indicated MR examination analysis of risk versus clinical benefit of performing MRI examination."
He further explained that code 76017 requires "a medical physicist or MR safety expert that looks over your whole case, makes suggestions to where the MRI images should be directed, and actually has a game plan for how to mitigate the risks." For code 76018, he emphasized it must be performed "while in the MR room with the written report" and requires "a separate individual performs additional preparation of the electronic implant into an MRI protective mode - immediately before entry into the MR environment."
Five: Prostate Procedure Transformation
The new prostate procedure codes (55881-55882) represent significant technological advancement. Dr. Steinbacher emphasized their revolutionary nature: "What separates this from other prostate surgeries is that other prostate surgeries are very, very traumatic. And they result in a lot of side effects. So, what this does is not only is it using ultrasound, but it's getting precise guidance, using the MRI to put the ultrasound waves exactly where you want to ablate the tissue."
Importantly for health plans, these procedures have specific limitations. As Dr. Steinbacher noted, they are "only for treatment of cancer that's localized to the prostate... not procedures that are recommended for patients with cancer that is either outside of the capsule or metastasized."
Six: Laboratory and Pathology Evolution
Several new diagnostic testing codes reflect advancing technology. Code 81195 introduces cytogenomic (genome-wide) analysis via optical genome mapping. Dr. Steinbacher described this as "a way for a computer - and AI does some of this stuff too - to look at an image and look at all the different types of fluorescent dyes on a stained piece of tissue."
Code 81558 advances transplantation medicine through gene expression profiling by quantitative polymerase chain reaction (qPCR) of 139 genes. He states that this is "like a liquid biopsy where you can draw some blood and look to see if there are signs of tissue rejection in that allograft organ."
Additional pathology updates include new codes for bacterial vaginosis testing (81515), beta amyloid testing, and tau proteins associated with cognitive disorders, though Dr. Steinbacher suggested some might still be considered "in the experimental and investigational category."
Implementation Guidance for Health Plans
These updates require careful evaluation of medical policies and payment integrity strategies. Dr. Steinbacher advised: "If you're part of the medical policy team and you're responsible for guiding or dictating medical policy around some of these new codes, you might want to categorize some of these codes and/or treatments as experimental investigation until those studies are complete."
To access comprehensive details about these updates and their implications for your organization's payment integrity program, visit Lyric’s webinar replay page to view the complete webinar recording. The session provides extensive guidance from both medical directors about implementing these changes effectively within your organization.
As health plans prepare for 2025, understanding these code updates becomes crucial for maintaining payment accuracy and appropriate coverage policies. The technological sophistication reflected in these changes requires careful attention to documentation requirements, coverage criteria, and medical policy development to ensure successful implementation.
About Lyric
Lyric, formerly ClaimsXten, is a leading AI healthcare technology company, committed to simplifying the business of care. Over 30 years of experience, dedicated, expert teams, and top technologies help deliver up to $14 billion of annual savings to our many loyal and valued customers—including 9 of the top 10 payers across the country. Lyric’s solutions leverage the power of machine learning, AI, and predictive analytics to empower health plan payers with pathways to increased accuracy and efficiency, while maximizing value and savings. Lyric is investing in AI driven technology to ease implementation and speed to value for customer savings, while offering enhanced and newly available solutions through internal product development and strategic partnerships, including recently announced partnerships with Concert Genetics, Autonomize AI, and now, Codoxo. Discover more at Lyric.ai.
