The Otolaryngology Coding Coach 2008 Archives

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.

Question:  

We are debating how to code for sublingual allergy therapy.  One of the nurses thinks we should use 95165; three of us think that is not correct.  What do you recommend?

Answer: 

Our teaching remains the same on the issue of SLIT.  We recommend using the unlisted code or an internal dummy code to track.  Below is Medicare's NCD as well as direction from JCAAI below.

110.9 - Antigens Prepared for Sublingual Administration
(Rev. 1, 10-03-03)
CIM 45-28

For antigens provided to patients on or after November 17, 1996, Medicare does not cover such antigens if they are to be administered sublingually, i.e., by placing drops under the patient’s tongue. This kind of allergy therapy has not been proven to be safe and effective. Antigens are covered only if they are administered by injection.

5/3/06 - Dear JCAAI Member:

As you are aware, the Joint Council of Allergy, Asthma and Immunology (JCAAI) represent your interests in a variety of areas where allergists are not the sole provider of patient services. For example, in regard to CPT and Medicare payment determinations, allergists share responsibility for providing information or obtaining new codes with pulmonary medicine and/or otolaryngologic allergy. Both Medicare and various AMA committees involved in coding or reimbursement, require that allergy present mutual issues jointly with these other specialties. They will not mediate disagreements between specialties. This obviously applies to all of medicine and not just to allergy and immunology.

This past summer when JCAAI had a variety of codes involving allergy testing or immunotherapy, we spent many hours with the ENT allergy physicians developing a joint presentation. Allergists and ENT allergy physicians understand that while there are areas in which we all agree, many practice differences still exist. Fortunately, these differences do not prevent our coming to agreement in areas of mutual concern.

In spite of continuing differences, JCAAI has developed collegial relationships with ENT allergy which allow us to jointly represent your interests and the interests of the ENT allergy community. In the same way, JCAAI recently worked with our pulmonary colleagues in presenting a request for a code for exhaled nitric oxide measurements and for pricing such a code, should our initial request be granted.

Currently, there is a great deal of action involving the provision of sublingual immunotherapy (SLIT). JCAAI has agreed to work with ENT allergy to develop guidelines for the kind of data we will need to present, if SLIT is ever to receive FDA and CPT approval. We have jointly agreed not to request a CPT code for SLIT at this time, since we do not believe that the evidence to support the application for such a code currently exists in the United States.

JCAAI is aware that, in the past, many of our members frowned on working with other specialties. I hope you understand that it is imperative that we work closely with other specialties in certain situations, particularly when it is helpful for us to achieve our goals. This should clarify our position and JCAAI appreciates your ongoing support of our efforts.