The Otolaryngology Coding Coach 2006 Archives

Question:

My billing manager just came to me and told me that she read that Medicare reversed a CCI edit bundling excision of malignant lesions (1164x) series of CPT codes as no longer bundled in the adjacent tissue transfer. It was my understanding that it was incorrect coding to report an excision of lesion code with the adjacent tissue transfer codes per CPT coding rules. Can you help sort this out? Are the lesions separately reportable or not?

Answer:

You are correct. Per the AMA CPT Coding Rules, the excision of a lesion is included in the adjacent tissue transfer (140xx). The adjacent tissue transfer is performed to close a surgical created defect. If the surgeon had not created the defect, there would be no repair in the case of lesions. This concept applies to lesions.

The following is an excerpt from CPT Assistant, Q&A July 2000, “When adjacent tissue transfer is required to repair a defect resulting from excision of a lesion, only the tissue transfer repair code (14000-14300) would be reported. For example, if a lesion measuring 3 sq cm is removed from the abdomen, resulting in a 6 sq cm defect that requires an advancement flap to perform the repair, CPT code 14000, Adjacent tissue transfer or rearrangement, trunk; defect 10 sq cm or less, should be reported. This code reflects the work involved in creating and placing the advancement flap, as well as the work of excising the skin lesion.”

While Medicare had edits in place on these code combinations and then reversed, them, is not relevant. Per CPT rules, the codes may not be reported together, which means Medicare did not even have to create edits because it is not correct coding to report together if the adjacent tissue transfer is performed to close a defect created by the excision of a lesion (benign or malignant)

Question:

Our physicians have a question about how to report an E&M service when the patient is unconscious and they cannot obtain a full history. Since consults and hospital admission codes require documentation of 3 out of 3 key components, how do we handle the history if the patient is unconscious?

Answer:

Good question and hopefully this is a situation that is an infrequent occurrence.

According to the AMA CPT Guidelines, the physician in this situation is given “credit” for a comprehensive history. The following is an excerpt from the AMA CPT Assistant regarding E&M documentation criteria. You will note in the statement, that this is a combined Medicare (now CMS, formerly HCFA) and AMA position.

On April 27, 1998, the American Medical Association convened the physician leaders and staffs of organized medicine for an open and candid exchange of opinions and concerns with representatives from the Health Care Financing Administration, Health and Human Services Office of the Inspector General, and the CPT Editorial Panel.

In response to physician concerns and vigorous advocacy efforts by the AMA, state medical associations, and medical specialty societies, HCFA officials announced at the meeting that it has agreed to: "Add a clear note that, when a history cannot be obtained due to specific patient conditions (e.g., inability to communicate urgent, emergent situation, etc.), the history is deemed "comprehensive" for coding and documentation purposes."

Question:

Our physician performed a partial thyroidectomy, pathology returned positive and the physician took the patient back to the operating room for a completion thyroidectomy. Our surgeon was told to append a modifier 79 (unrelated surgical procedure) and I am saying modifier 58 (staged or related procedure) because the completion thyroid is more extensive surgery for the disease process. Which modifier is correct?

Answer:

Modifier 58 is the correct modifier in this situation. The physician is still treating the thyroid disease and the subsequent procedure is more extensive as it requires complete removal of the thyroid to treat the disease process. While some may advise modifier 79 because the diagnosis changed from a benign pathology to a malignant pathology, he is still treating the same anatomic area.

Question:

Our surgeon saw a trauma patient who had a laceration repair by the ER physician and presented to our office for follow-up care. Our surgeon removed the sutures and wants to know how to report this procedure?

Answer:

Suture removal may only be reported if the sutures are removed in the operating room under anesthesia (other than local), either by the physician who placed the sutures (CPT code 15850) or by a physician other than the surgeon who placed the sutures (CPT code 15851). Sutures removed in the office are either part of the 10 day global period, or in your scenario, part of the E&M service.

Question:

Is it permissible to bill for a follow-up visit after the 10-day global period for tube insertion if the patient also had an adenoidectomy and or tonsillectomy at the same time since those procedures each have a 90-day global period?

Answer:

If the patient is seen outside the global period of the tube insertion, and the physician performs an E&M service, an established patient visit may be reported and appended with a modifier 24. The diagnosis will be related to the ears. The intent of a ten-day global is that the payment for the surgical procedure includes one post-operative visit.

Question:

Our physician treated a patient over a series of a couple of days for a nosebleed. He finally placed a posterior pack and also placed anterior packs at the same time. Can you report both the anterior and posterior packs at the same session?

Answer:

No, anterior packs are included in the posterior packs and as such are not separately reported. CPT code 30905 Control nasal hemorrhage, posterior, with posterior nasal packs and/or cautery, any method; initial is a unilateral or bilateral code, thus may only be reported one time per session.

Question:

If the surgeon performs a tympanoplasty and harvests a tragal cartilage graft or other graft through a separate skin/fascial incision, can the graft be reported in addition to the tympanoplasty?

Answer:

Yes, if the surgeon performs for example, a transcanal tympanoplasty and then harvest a graft such as a tragal graft, you may report both 69631 and 21235-59. Key is the modifier 59 to indicate the graft was taken from a separate incision. If s/he harvest fascia, the code would be 20926-59. Report the appropriate graft code based on what tissue was harvested from the separate site through a separate incision. If the graft is harvested locally, the graft may not be reported separately.

Question:

CPT code 30930 confuses me. The code says “turbinate(s)”. Do I report this code bilaterally using a -50, or does the (s) mean that it is a bilateral code?

Answer:

Good question. This is one of the reasons the AMA continues to try to make the language consistent in the CPT book. In this case, the (s) on “turbinate(s)” refers to one or all three turbinates on the same side (superior, middle and/or inferior). Thus, the code is a unilateral code and may be reported twice if the physician performs turbinate surgery on both sides of the nasal cavity.

If we look at the Medicare fee schedule, we will see there is a number 1 in the fee schedule definition. This means that the 150% payment adjustment for a bilateral procedure applies, meaning Medicare would pay for a bilateral procedure according to their normal payment policy

Question:

We have an audiologist in our practice performs an ENG tests on a patient who has never been seen by our physicians. The patient returns his appointment with our physician who now reports an E/M service. Do you report the service as a new patient or established patient?

Answer:

The ENG hearing tests you are reporting to the insurance company has a professional component for the interpretation of the tests by the physician. According to the AMA’s definition of new vs. established patient, the doctor has provided service within the past three years and therefore an established patient visit would be reported. (From the CPT Assistant June 1999: It is very important to note that the definitions of new and established patients do not refer to patients being seen by the physician (ie, having a face-to-face physician/patient encounter), but rather as receiving any professional services.

It is possible for the patient to have received professional services from a physician (eg, renewing a prescription) without actually having a face-to-face encounter with the physician. If the patient has received a professional medical service from the physician, other than for administrative reasons (eg, responding to a question about office hours), then the patient would not be considered a new patient, but rather an established patient).

Confusing as it may seem, Medicare says just the opposite. If no E&M service is provided in three years but services such as lab or diagnostic test interpretations are performed, then the patient is a new patient.(CMS 30.6.7; B3-15502; 10-01-03).

Question:

I am doing an internal audit for our practice. I have come across some claims where I see an E&M and procedure reported on the same day and the diagnosis that is linked to the E&M is not the reason the patient presented for the visit in question. For example, the patient has been treated in the past for otitis media and now presents for evaluation of increasing hoarseness. The Otitis media has resolved and the physician does not do any history or exam related to the otitis, instead focuses on the hoarseness and performs a fiberoptic laryngeal exam. The claim was submitted as: 99213-25 linked to otitis media and 31575 linked to hoarseness. I do not think this is correct, but since we are just beginning our auditing process, I want to make sure I am correct in my assessment.

Answer:

You are absolutely correct in your assessment. Since the physician is not evaluating or managing the patient for otitis media and the condition is resolved, this diagnosis should not be linked to the E&M. If the physicians’ E&M service is a significant service, then the physician should report the E&M -25 along with the 31575. Both diagnosis would be hoarseness, unless the physician determines a more definitive diagnosis after the flexible fiberoptic laryngeal exam. If the E&M is not the significant service, the physician would report 31575 alone.

Question:

We are a new otolaryngology practice and the physician is performing allot of endoscopic sinus cases. He is also performing a septoplasty at the same time in many of the cases. We are receiving denials for medical necessity and are unsure why. Do you have any suggestions for us?

Answer:

This is a good question and we are glad to see you are paying attention to the EOB’s and trying to figure out why the payor is rejecting the service for medical necessity. The first place to begin will be to make sure you are using and appending the correct diagnosis codes to the correct procedures. Here are a few tips to check.

• Are you using specific sinus diagnosis codes such as acute or chronic maxillary sinusitis, acute or chronic ethmoid sinusitis, etc? If not, this is critical to ensure the medical necessity supports the procedure.
• Are you using pansinusitis diagnosis instead of the specific sinus diagnosis code? If yes, stop using this code and use the more specific sinus code as identified in the first tip.
• Are you linking septal deviation or airway obstruction diagnosis codes to the sinus or linking sinus diagnosis codes to the septoplasty? If yes, change how you are linking the diagnosis codes. A septal deviation diagnosis or airway obstruction diagnosis code are not typically the medical reason you are performing sinus surgery ,and likewise, you typically do not perform a septoplasty for sinus disease. If the septoplasty is performed to gain access to the sinus, it is not separately reportable.

Try using these tips to analyze your claims and why the payor may be rejecting. Keep us posted on your findings.

Question:

Our physician performed an endoscopic ligation of the spenopalatine artery for a posterior nosebleed. Is CPT code 31238 the correct code for this procedure?

Answer:

|We recommend using the unlisted accessory sinus code, 31299 instead of CPT code 31238, Nasal/sinus endoscopy, surgical; with control of nasal hemorrhage since there is no CPT code for ligation of the artery.

Question:

We have several physicians who perform a planned tracheostomy at the bedside (CPT code 31600) and also administer the anesthesia. Can you bill anesthesia in addition, and if yes, how would you code it? Are payors reimbursing for anesthesia by the surgeon?

Answer:

This is an instance of coding versus reimbursement rules and will depend on type of anesthesia administered. According to the CPT Surgical Package Definition, the surgical procedure includes “Local infiltration, metacarpal/metatarsal/digital block or topical anesthesia”. If the surgeon is performing IV conscious sedation, you may report this, in addition to the surgical procedure, according to CPT. In 2006, the AMA introduced an entire new series of Moderate (Conscious) Sedation codes that differentiate age of patient, who performs the procedure and/or who administers the sedation, and based on time. So those are the coding rules! Medicare will not reimburse for any anesthesia services administered by the operating surgeon.

Question:

Our physician recently submitted an operative note and requested help in coding the case. He performed what he calls “ a balloon sinuplasty”. He says he opened the maxillary sinus by dilating the opening with this new endoscopic catheter that has a balloon. He explains that this similar to a balloon dilation of a heart vessel. We are not sure how to code this. What do you recommend?

Answer:

This is an interesting case and not without controversy. The AMA has set a precedent by creating specific CPT codes for procedures performed with balloon dilation in other specialties. As a result, the standard is to use the balloon dilation codes where they exist or to use an unlisted code for procedures when no specific CPT code for a service exists. Since there is no CPT code to describe the balloon sinuplasty, these procedures must be reported using the, “Unlisted, sinus accessory code 31299” versus the CPT code for the standard procedure. For example, if the physician performs a maxillary antrostomy via balloon dilation, the procedure is reported with the 31299 code versus CPT code 31256.