The Otolaryngology Coding Coach 2004 Archives

Question:

My doctor always removes tonsils on both sides. So should we bill the tonsillectomy code with modifier -50 (bilateral procedure)?

Answer:

No. The tonsillectomy codes, and adenoidectomy codes for that matter, assume both side surgery. Therefore, it is not appropriate to append modifier 50 to any of the tonsillectomy or adenoidectomy codes (ie, 42820-42836). The February 1998 CPT Assistant says to append modifier 52 (reduced services) to the appropriate CPT code when performed unilaterally (eg, unilateral tonsillectomy for suspected cancer).

Question:

What is the code for “snoreplasty”?

Answer:

There is no CPT code for this procedure. If you are going to bill this to a third-party payer use 42999 (Unlisted procedure, pharynx, adenoids, or tonsils). If not reporting to an insurance company, we recommend using a “dummy” code, you set up in your computer system, for patients who pay cash. This will keep cash procedures separate from insurance-billed procedures and maintain clean reimbursement data for the codes reported.

Question:

The physician reported a laryngoscopy, total parotidectomy, and an alloderm implant to the neck. He used the alloderm to fill the defect after the resection. Can he use the 20926 code with a modifier 52?

Answer:

The physician may not separately report the alloderm implant. The CPT codes for the cartilage grafts, fascia grafts, bone grafts and tendon grafts are appropriate when the physician harvests an “autograft” not for the placement of the grafts. Allografts are not separately reportable unless the physician is treating a burn or operating as an assistant surgeon in the spine, where there are specific codes related to those procedures using allografts.

Question:

If the audiologist tests only one ear, do I need to attach a 52 modifier for reduced services since the audiologic testing codes are for both ears? The audiologist seems to think so, but I don’t.

Answer:

Look in the CPT book at the guidelines right after the heading “Audiologic Function Tests with Medical Diagnostic Evaluation (92551-92597)”. The guidelines specifically say “All descriptors refer to testing both ears. Use the modifier 52 if a test is applied to one ear instead of to two ears.” We agree with your audiologist.

Question:

The physician performed a total laryngectomy and neck dissection on January 19. On February 2nd, the patient presented to our office with complaints of leg pain, swelling and warmth in his left lower leg. The physician evaluated the patient and suspected a deep venous thrombosis and sent him to the hospital for testing. Can the physician report an E&M service for this visit or is it included in the global surgical package.

Answer:

While the deep venous thrombosis (DVT) is an untoward outcome after surgery, it is not a complication of the surgical procedure performed, the total laryngectomy and neck dissection. The physician may report an established patient visit and must append the modifier 24 (unrelated E&M during the global period). Make sure the appropriate diagnosis is linked to the E&M service (diagnosis related to leg pain, swelling).

Question:

Our physician recently showed us an operative note where she removed polyps from the right and left vocal cords. She wants to know if she can report these as bilateral procedures similar to when she performs sinus surgery? She sometimes will do these procedures with the operating microscope, but not always.

Answer:

CPT codes 31540 Laryngoscopy, direct, operative, with excision of tumor and/ or stripping of vocal cords or epiglottis; and CPT code 31541Laryngoscopy, direct, operative, with excision of tumor and/ or stripping of vocal cords or epiglottis; with operating microscope describe the procedure on the vocal cords. The larynx is considered a central structure, thus procedures are not typically reported as bilateral procedures. The verbiage in CPT 31540 and 31541 both state "vocal cords" thus these codes are reported one time only as the procedure includes both cords.

Question:

My doctor is going to do a translabyrinthing removal of acoustic neuroma with a neurosurgeon next week. How should I code this procedure?

Answer:

The appropriate CPT code is 61526 (Craniectomy, bone flap craniotomy, transtemporal (mastoid) for excision of cerebellopontine angle tumor). Usually one surgeon, typically the neurotologist (ENT), performs the approach while the other surgeon (the neurosurgeon) removes the tumor.

This is a class example of where the co-surgery modifier, 62, is used; when two surgeons of different specialties share a single CPT code. Therefore, both surgeons will report 61526-62 to the payor.

Question:

Our ENT doctor does the cervical exposure only for the neurosurgeon to perform anterior cervical fusion & diskectomy. What code do I use?

Answer:

You will use one of the neurosurgeon's CPT codes (eg, fusion or decompression/diskectomy) with modifier 62 (co-surgery). Remember, all stand-alone CPT codes include the exposure, resection and closure. Therefore, modifier 62 is appended to a single procedure code when one surgeon does not perform the entire code and it is a shared service.

In this scenario you have two options: append 62 to code 22554 (anterior cervical arthrodesis/fusion) OR code 63075 (anterior cervical decompression and diskectomy). Both are stand-alone codes which include the anterior exposure, or approach, to the cervical spine. It's important to discuss the coding with the neurosurgeon's office so both surgeons submit a claim with 62 appended to the same single CPT code.

We recommend you report your usual full fee for the CPT code billed. The payor will apply a "co-surgeon payment formula" for reimbursement. Medicare allows 62.5% of the allowable for each surgeon reporting the same code with modifier 62.

Question:

Does the physician need to be in the office suite when allergy injections are given to Medicare patients? If so, can just the Nurse Practitioner, who has her own provider number with Medicare, be present? Would we have to code it under her number?

Answer:

The physician reporting the service, by billing it to Medicare, must be present in the office suite when an allergy injection is given. The physician will be reimbursed 100% of the physician allowable for this service.

If, however, the Nurse Practitioner is present (and the physician is not) and supervising the injection activity then you may report the service to Medicare using the NP's name and Medicare provider number. Medicare will reimburse the NP at 85% of the physician allowable.

Question:

We have patients who come in every three to six months for a trach tube change. We use 31502 for this procedure but someone recently told me that isn't correct. What do you think?

Answer:

The CPT descriptor for 31502 is "Tracheotomy tube change prior to establishment of fistula tract". It is appropriate to use 31502 if the trach tube is changed prior to the healing of the fistula tract. While the timing of this is the physician's call, generally the time period for healing is around 7-10 days after the tracheostomy is created. Use an E&M code to report the trach tube change after the fistula tract has already healed

Question:

Our office would like to confirm that for ENG's, if your billing for the comprehensive code, both technical and professional component that a physician must be in the building when the test is performed by a qualified audiologist.

Answer:

If the person performing the ENG is a qualified audiologist (as defined by Medicare), the supervision rules that are applied are the diagnostic testing supervision rules and not the incident-to rules. Transmittal B-01-28 (April 19, 2001) addresses Medicare's revised levels of physician supervision for diagnostic tests payable under the Medicare physician fee schedule. Physician supervision rules do not apply when audiology diagnostic tests are performed by a qualified audiologist, thus only general supervision rules apply.

Question:

How do I report Botox when the physician is only using the medicine on one patient? We are not using the entire volume?

Answer:

Botox is generally supplied in vials, each containing 100units. Per Medicare instructions, if less than 100 units are administered during a single treatment session , report the 100 units in the days/units box on the CAS 1500 claim form. Medicare will reimburse for the unused portion of the vial when the vial is not split between patients.

Per Medicare instructions, if the physician schedules multiple patients requiring Botox on the same day, report the exact dose of Botox in the units box for each patient. In both instances, make sure the medical record supports the documentation of the amount of Botox administered to the patient.

Question:

One of our physicians was called for an inpatient consult on a patient with a trimalar fracture. The patient was discharged and then re-admitted by another physician five days later. Our physician was called, again, for another consult by the second admitting physician. Do we charge for a F/U consult for the second visit or do we charge for another inpatient consult?

Answer:

It would be appropriate to report an inpatient consultation code (9925X), when the physician is consulted again during a different hospital admission.