The Otolaryngology Coding Coach 2008 Archives

Question:

When a return patient comes for routine removal of cerumen, what should the chief complaint be (eg, I'm here for wax removal, my ears are plugged)?  Also, which code(s) is/are best to use for removal of cerumen impaction - 1 99212 (level two established patient visit), use of binocular microscope (92504), cerumen removal (69210)?  What documentation is recommended for the chart?

Answer: 

Any of the above chief complaints are fine for documentation purposes.  The CPT code that best represents the situation you describe is 69210 (Removal impacted cerumen (separate procedure), one or both ears).  It would not be appropriate to also bill a 99212 because the purpose of the visit, as you desribe, is for removal of cerumen. A brief statement about the reason for the visit and a procedure description for the removal of impacted cerumen is required to support reporting 69210.

Thyroid Aspiration Code

Question:

We are confused by the new CPT code 60300. It reads exactly as the deleted code 60001.  Can you explain the rationale for this change?

Answer:

As the AMA continues to create consistencies in CPT code placement with headers, the old code 60001 was removed from the “excision” section since the work associated with this code does not reflect an excision.   Thus the old code was deleted and the new CPT code 60300 was created with the same definition, Aspiration and/or injection, thyroid cyst.   The AMA kept the Guideline instructions from CPT code 60001 with the creation of CPT code 60300, instructing the physician to report image guidance (76942, 77012) in addition to 60300 when performed.  An additional reference to use the 10021-10022 for fine needle aspiration was also added. 

Radium Implants

Question:

Our surgeon took his patient to the OR for insertion of radium implant catheters and the radiation oncologist placed the radium in the room after the patient returned from the recovery room.  How does the surgeon report the placement of the catheters?

Answer: 

The AMA introduced a new CPT code this year for the placement of interstitial catheters. 

CPT code 41019 describes Placement of needles, catheters, or other device(s) into the head and/or neck region (percutaneous, transoral, or transnasal) for subsequent interstitial radioelement application.

If the physician uses image guidance to place the catheters/needles/device, the guidelines instruct the physician to report the appropriate radiological guidance code (76942, 77002, 77012, 77021) in addition to CPT code 41019.  The surgeon would append modifier 26 to 76942, 77002, 77012, 77021 and must dictate a separate interpretation of the image guidance.  

Percutaneous Gastrostomy

Question:

Our surgeon documented the placement of a percutaneous gastrostomy tube using fluoroscopic guidance on one of our head and neck oncology patients.  Is there a CPT code to use for this procedure or do we have to use an unlisted code?  Is the fluoroscopic guidance separately reportable?

Answer:

The surgeon would report CPT Code 49440 Insertion of gastrostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report

This code includes fluoroscopic guidance so the 77xxx codes would not be reported in addition to CPT code 49441.  By definition, the surgeon must have a digital or paper image of the fluoroscopic guidance and must dictate a separate interpretation of the fluoroscopic guidance.

Diagnosis Code for Conversion to Open Procedures

Question:

I found diagnosis codes for the conversion of a laparoscopic procedure to an open procedure, thoracoscopic procedure to an open and arthroscopic procedure to an open, but I did not find an endoscopic converted to an open. Is there a diagnosis code for an endoscopic procedure converted to an open. 

Answer:

No, while we saw the addition of the thoracoscopic and arthroscopic conversion to open procedure diagnosis codes, there is not a diagnosis code specific to the conversion of an endoscopic procedure to an open?

Question:

How do we code an endoscopic thyroidectomy that the surgeon had to convert to an open procedure because he was not able to complete the procedure endoscopically?    

Answer:

The surgeon reports the appropriate open thyroid CPT code.   If the documentation supports significant work over and above the normal open procedure, the surgeon may append modifier 22 to the open CPT code. 

Question:

We recently began receiving rejections from Medicare because we did not have an entry in Box 11 on the CMS 1500 claim form.  Medicare is telling us we must put NONE in the box if there is no primary Insurance.  This has never happened before.

Answer:

We researched this question and found the following instructions in the Medicare Manual.  The Medicare instructions state that if the patient does not have any primary insurance to Medicare, the word “none” must be entered in box 11.  Here is the excerpt form the Claims Submission Instruction section related to the question.

Item 11 -THIS ITEM MUST BE COMPLETED, IT IS A REQUIRED FIELD. BY COMPLETING THIS ITEM, THE PHYSICIAN/SUPPLIER ACKNOWLEDGES HAVING MADE A GOOD FAITH EFFORT TO DETERMINE WHETHER MEDICARE IS THE PRIMARY OR SECONDARY PAYER. If there is insurance primary to Medicare, enter the insured's policy or group number and proceed to items 11a - 11c. Items 4, 6, and 7 must also be completed. NOTE: Enter the appropriate information in item 11c if insurance primary to Medicare is indicated in item 11. If there is no insurance primary to Medicare, enter the word “NONE” and proceed to item 12.

We believe that although the policy existed before, it was not enforced as zealously as CMS wanted.  Your recent denials are likely due to this fact.