The Otolaryngology Coding Coach 2005 Archives

Question:

We have a physician who wants to report an E&M service and an Epley maneuver on a Medicare patient. Can you instruct us on how to do this?

Answer:

Great timing! Per a recent release from Medicare, they have again communicated that the Epley Maneuver is reported using the unlisted procedure code, 92700. Medicare will cover the Epley Maneuver for Vertigo. However, Medicare states that if an E&M service is also reported at the same visit, the 92700 code will be denied as included in the visit.

Question:

One of our physicians saw a hospital patient for a consultation. He did not perform an exam but spent time talking to the patient and wife. The dictation includes a history and discussion but there is no record of an exam. How can I code the inpatient consult without the exam?

Answer:

You mention that the physician spent time talking to the patient and his wife. Did the physician document the total visit time (unit time) and the percent of the time spent on counseling? If yes, you may choose the correct inpatient consultation code (9925x) based on time. Remember, in the inpatient setting, time is total unit time and not just face to face time. However, the physician must have documented the total time and time spent counseling in the documentation you mentioned.

The second option if the time requirement is not met is to report an unlisted E&M code 99499 and send the claim via paper with the note.

Question:

Do we use modifier-52 for reduction of turbinates when the physician states “radiofrequency ablation?”

Answer:

Radiofrequency ablation typically implies volumetric reduction of mucosa. By definition, CPT code 30801 (Cauterization and/or ablation, mucosa of turbinates, unilateral or bilateral, any method, (separate procedure); superficial) or 30802 (Cauterization and/or ablation, mucosa of turbinates, unilateral or bilateral, any method, (separate procedure); intramural) appear to be more appropriate codes for this activity. Alternatively you may report an unlisted code such as 30999.

Question:

I keep hearing it is the coder’s choice to append modifier -51 or not to a surgical procedure. But CPT instructions state to append the modifier 51 when performing multiple stand-alone procedures during the same operative session. What do you recommend?

Answer:

You are absolutely correct in your understanding of CPT’s definition of modifier -51. Like you, we keep hearing people recommend not appending modifier -51to secondary, subsequent procedures. But, CPT instructions are clear append -51 when you are reporting multiple stand alone procedures performed at the same operative session. The one exception is if you have received written instructions from a specific payor directing you not to append the modifier because they have their computers set to automatically apply the multiple procedure payment formulas. We recommend you follow that specific payor’s rules but not to adopt that payor’s preference across the board to all payors.

When you do not append the modifier-51 to the appropriate procedures, you risk the payor re-ordering and reducing a higher valued procedure and reimbursing you 100% on a lower valued procedure. Additionally, you also risk the payor appending the multiple procedure payment formula to add-on or exempt codes. You never append modifier 51 to either one of these codes.

Question:

Can modifier-22 be appended to a surgical procedure code when the physician performs additional procedures that are considered bundled or incidental to the primary procedure?

Answer:

No, modifier 22 is used to indicate unusual procedures above and beyond the normal range of complexity for a given CPT code. For instance if a surgical CPT code includes an incidental procedure that cannot be reported separately, per CPT rules, it is not accurate report to append a modifier 22 just because you aren’t allowed to bill separately for the incidental procedure.

Let’s say the physician performs an inferior turbinate submucous reduction and then cauterizes the bleeding. The cauterization (e.g., 30801, 30802) is included in the primary procedure for the inferior turbinate submucous resection (30140). It is not appropriate to append a modifier 22 just because the surgeon can’t report the cautery code .

Here’s a second example the doctor performs middle turbinate surgery in addition to endoscopic sinus surgery on the same side. Surgery on the middle turbinate is included as gaining access to the sinuses, thus it would not be accurate to append modifier 22 for the turbinate work.

This “gaming” is a bad idea.

Question:

I was at a seminar recently and the instructor defined modifier 26 as a surgical modifier. I was confused because this modifier is used when the physician reports the professional interpretation of a diagnostic test, right?

Answer:

You are correct modifier-26 is not a surgical modifier. And you’re right again

-26 is appended to a diagnostic code when reporting the professional interpretation of a diagnostic test. Typically this occurs in the office, however, it may be in the hospital, if the diagnostic procedure is performed during surgery by another physician.

For example, let’s look at intraoperative monitoring, CPT code 95920 says: “Intraoperative neurophysiology testing, per hour (List separately in addition to code for primary procedure).”

If a neurologist is performing the intraoperative monitoring while the ENT is doing acoustic neuroma surgery, the neurologist would report 95920-26 to indicate s/he is only reporting services for the professional component assuming s/he did not also own the monitoring equipment.

So, as you see, modifier –26 can be used during a surgical procedure, but it’s not appended to a surgical CPT code. Rather modifier –26 is appended to the diagnostic procedure code that includes both professional and technical components.

Question:

Can we charge for photopcopying records for attorneys, disability claims, etc? I heard that some of our state agencies have a monetary limit but what about private payers?

Answer:

Check your state laws on guidelines for medical record photocopying. Your state's medical association should have this easily available to you. Typically the regulations apply to all payers, not necessarily state vs. private payers.

Question:

Occasionally we will have a patient who sees two of our physicians on the same day because our physicians are subspecialists in ENT. For example, the patient is seen by two different doctors for his/her sinus problem and ear problem. We billed for both E&M services but only one physician was paid. What can we do to get payment for the other physician?

Answer:

It is a reimbursement problem when two physicians of the same specialty, in the same group practice, see a patient on the same day. It is not a reimbursement problem with two physicians of different specialties, in the same group practice, see a patient on the same day (e.g., your doctor and the internist).

Generally payers do not recognize physician subspecialties. Therefore, they will reimburse for one E&M service per day per specialty in the same group practice. You can appeal for payment on the denied service by submitting both E&M progress notes to show that two separate services were indeed provided by two different physicians. Explain, in a cover letter, the subspecialty nature of your physicians’ expertise (e.g., fellowship training). Good luck!

Question:

We were told at a coding course to bill 92547 (Use of vertical electrodes (List separately in addition to code for primary procedure)) once for each of the other ENG codes billed that day. For example, for a full ENG we bill 92541, 92542, 92543 times 4 units, 92544, and 92545. This instructor said to bill 92547 eight times. We’ve been doing this for a few years and occasionally get paid. How come we aren’t paid all the time?

Answer:

CPT code +92547, use of vertical electrodes is an add-on code that KZA has always recommended to be reported once per session of an electronystagmography (ENG). This is validated in the May 2004 CPT Assistant, published by the American Medical Association.

However, Medicare's RVUs for +92547 dropped dramatically on January 1, 2005 reflecting a change. According to the February 2005 CPT Assistant, "this code may be reported "per test" in addition to the code(s) for the primary procedure(s) for each vestibular test performed." CPT realizes that Medicare's policy has changed and now supports reporting +92547 for each unit of vestibular testing performed. In your example, if you perform eight tests, then you would report +92547 with eight units.

Keep an eye on payments from your non-Medicare payors to see if they follow Medicare's changes in policy.

Question:

How should we code the radiofrequency procedure on the base of tongue to treat sleep apnea? The manufacturer of the equipment we purchased told us to use a glossectomy code with modifier –52 (reduced services).

Answer:

You are wise to verify coding advice from vendors! While some do provide accurate advice, others paint a “rosy” reimbursement picture to entice your purchase of their equipment.

There is a new Category III CPT code for this procedure in 2005 – 0088T that states “Submucosal radiofrequency tissue volume reduction of tongue base, one or more sites, per session (ie, for treatment of obstructive sleep apnea syndrome).”

Be sure to obtain written prior authorization from payors for this procedure as many consider radiofrequency technology “investigational” and do not reimburse.

Question:

How would you code for placement of bilateral tympanostomy tubes? The otolaryngologist placed a PE tube in each ear. I coded: 69436, 69436-59, but would like a second opinion.

Answer:

We recommend using the bilateral modifier -50 in this case because 69436 is a CPT code that is recognized as unilateral and “accepts” modifier -50. So the proper coding would be either of the following two options:

Option 1)

Code is listed on a single line with modifier -50: 69436-50. Usually the number 1 is listed in the “units” box on the claim form but check your individual payers for their preference; an occasional payer may require 2 in the “units” box.

Option 2)

Codes are listed on two lines and the second code is appended with modifier -50: 69436, 69436-50. The number 1 is listed in the “units” box on the claim form for each line.

Most Medicare carriers require the format presented in Option 1 and recognize that as two procedures; the reimbursement is 150% of the allowable. Use this format for payers who recognize, and pay, a single line as two procedures.

The format in Option 2 has the same intent as the format in Option 1; meaning bilateral procedures were performed. However, many payers will only recognize and pay for bilateral procedures if they are listed on two separate lines on the claim form.

Question:

Can two surgeons of the same specialty be co-surgeons or can physicians only report services as co-surgeons if they are from different specialties?

Answer:

The AMA revised the definition of modifier 62 Two Surgeons in 1999.

PER AMA CPT:

The following definition for modifier -62 Two Surgeons existed in 1998

“Under certain circumstances the skills of two surgeons (usually with different skills) may be required in the management of a specific surgical procedure. Under such circumstances the separate services may be identified by adding the “-62” modifier to the procedure for reporting his services.

In 1999, the AMA revised the definition of modifier-62. Note, the descriptor change is found between side-lying triangles, indicating a change in the descriptor of the guidelines.

“When two surgeons work together as primary surgeons performing distinct part(s) of a single reportable procedure, each surgeon should report his/her distinct operative work by adding the modifier -62 to the single definitive procedure code. If the additional procedure(s) (including add-on procedure(s) are performed during the same surgical session, separate code(s) may be reported without the modifier ‘-62’ added. Note: If a co-surgeon acts as an assistant in the performance of additional procedure(s) during the same surgical session, those services may be reported using separate procedure code(s) with the modifier ‘-80’ or modifier ‘-81’ added, as appropriate.

While the new policy does not specifically state you have to be surgeons of different specialties, there are few examples of where this would be the case.

Refile claims for services performed 1/1/05 to date with the correct number of units. Remember, the number of units will equal the number of ENG codes/units (92541-92545) you bill.

Question:

One of our physicians is inquiring on how to code endoscopic approach to the pituitary? He says he's working with a neurosurgeon who will actually remove the tumor.

Answer:

CPT Code 62165: Describes neuroendoscopy, intracranial; with excision of pituitary tumor, transnasal or trans-sphenoidal approach. This was a new code in 2003.

This is a stand-alone code and includes the approach, tumor resection and closure. Therefore, if your otolaryngologist does this procedure with a neurosurgeon then both surgeons report 62165 with modifier 62 (cosurgeons). There is no separate CPT code for an endoscopic approach because the approach is included in 62165. It is not appropriate for the otolaryngologist to separately report codes for a septoplasty and/or sinus surgery rather than use 62165-62.

Question:

Can we charge for insertion of a Jackson-Pratt, or penrose, drain when the physician performs a parotidectomy or neck dissection? If so, what code would we use?

Answer:

You may not bill for this activity. Placing a drainage device in the operative field is included in the global package for any surgical procedure and not separately billable.

Question:

I am coding 40810 for laser treatment of multiple oral lesions. Because this was multiple lesions, how do I code this so each site is paid?

Answer:

In the situation you describe below, I would not recommend using the code you propose, 40810. The better code to describe a laser treatment of an oral lesion is 40820.

If the lesions are all completely distinct (eg, no border sharing and in separate locations) use CPT 40820 for each lesion. You might need a modifier 59 on the second and subsequent code(s). If the lesions have shared borders or are very close to one another in the oral cavity, report CPT 40820 once.

Question:

Our otolaryngologist was wondering who the “other appropriate source” is in the CPT consultation definition. CPT states a consult is a physician requested service but then goes on to refer to the “other appropriate source. The physician is wondering if a request from an audiologist or speech pathologist, physician assistant or nurse practitioner would constitute the other appropriate source?

Answer:

A "consultation" initiated by a patient and/or family, and not requested by a physician or other appropriate sourge (eg. physician assistant, nurse practitioner, doctor of chiropractic, physical therapist, occupational therapist, speech-language pathologist, psychologist, social worker, lawyer, or insurance company), is not reported using the consultation codes but may be reported using the office visit, home service, or domiciliary/rest home care codes.