The Otolaryngology Coding Coach 2009 Archives

December 17, 2009

Question:

I have a new surgeon who gave me an operative note for a right parotidectomy with preservation of the facial nerve.   He also dictated the insertion of a drain in the procedure title and was looking for a CPT code to report this procedure.    I suggested to him that the insertion of the drain was included and not separately reportable, but he wanted me to make sure.  He documents the insertion through a separate incision and he said he was told that anything done through a separate incision is reportable.   Is this a separately reportable service or is it included as I suggested?  

Answer:

You are correct!  The insertion of the drain at the surgical site is considered to be an integral part of the procedure and thus not separately reportable whether inserted through the same or separate incision.

November 12, 2009

Question:

Can we report outfracture procedures one time per case or can this code be reported for procedure twice if the surgeon documents outfracture on the right and left side?

Answer:

The AAOHNS recently clarified the definition of CPT code 30930 Fracture nasal inferior turbinate(s), therapeutic.    

The AMA revised CPT code 30930 to differentiate the procedure to define outfracture  work performed on the inferior turbinates only. When the code was revised, the AMA also provided a guideline instruction to use the unlisted procedure code 30999 for work on the middle or superior turbinates.  

According to the revised AMA definition since the code reads “turbinate(s)” CPT code 30930 may be reported one time per operative session and includes work on one or both inferior turbinates.  

Medicare reimbursement rules allow the procedure to be paid as a bilateral procedure as shown in the  Medicare payment schedule for CPT code 30930.

The AAOHNS recognizes that the AMA and Medicare are on two different fronts related to the coding and payment for this procedure.

If you do not have access to Code Manager, you may also search your Medicare Carrier Fee Schedule information to view Medicare reimbursement rules for CPT codes.

The arrow points to the Medicare Indicator for Bilateral Procedures. The definition for this indicator is found by clicking on the question mark in the green box.

Clicking on  reveals the following Medicare payment rules for CPT code 30930.

“150 percent payment adjustment for bilateral procedures applies. If code is billed with the bilateral modifier or is reported twice on the same day by any other means (e.g., with RT and LT modifiers or with a 2 in the units field), base payment for these codes when reported as bilateral procedures on the lower of: (a) the total actual charge for both sides or (b) 150 percent of the fee schedule amount for a single code.

If code is reported as a bilateral procedure and is reported with other procedure codes on the same day, apply the bilateral adjustment before applying any applicable multiple procedure rules.”

October 29, 2009

Question:

The surgeon performed an open biopsy of the cervical lymph nodes and is now planning to take the patient to the OR for a selective neck dissection.   Will I need a modifier on the neck dissection and if yes, which modifier

Answer:

It depends on when the patient is taken to the OR for the neck dissection. CPT code 38510 (Biopsy or excision of lymph node(s); open, deep cervical node(s)) has a ten day global period. If the surgeon returns the patient to the OR during the ten day global period, append modifier 58 (staged or related procedure) to the appropriate neck dissection CPT code. If the neck dissection is done outside the global period, no modifier is required on the neck dissection.

September 17, 2009

Question:

How do we report an endoscopic repair of a CSF leak after endoscopic sinus surgery. 

Answer:

The answer depends on the anatomic location of the repair. CPT codes 31290 and 31291 describe the procedures for the repair of a CSF leak performed endoscopically in the ethmoid and sphenoid region, respectively.  If the patient is in a global period, for a non-endoscopic sinus surgery, append modifier 79 (unrelated surgical procedure) to CPT codes 31290 or 31291 as appropriate.  Remember, the endoscopic CSF leak repair codes include the approach such as the endoscopic ethmoidectomy – don’t unbundle these codes.

September 4, 2009

Question:
Our surgeon performed a “functional” rhinoplasty (CPT code 30410) and harvested a septal graft for the reconstruction. Can we report a code for the septal graft in addition to the rhinoplasty or is it included?

Answer:

CPT code, 30410 (Rhinoplasty, primary;complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip) does not include the harvest of the septal graft because the graft is obtained through a separate surgical incision.  Thus if the surgeon documents the harvest of the septal graft, the surgeon may also report CPT code 20912 (Cartilage graft; nasal septum). Append modifier 51 to CPT code 20912 as it is the lesser valued procedure.

The graft harvest is separately reportable because there is no work performed on the septum in the situation you describe, such as a septoplasty.  However, if a septorhinoplasty were performed then the septal graft would not be separately reported.

Question:
What are the documentation requirements to support reporting CPT code 61795 in addition to the revision endoscopic sinus cases we perform?

Answer:
This code was originally designed and valued for significant physician pre-planning work when performed with intracranial primary procedure codes. When the code definition expanded to be used for extracranial or spinal procedures, it became appropriate to report with revision endoscopic sinus cases when medical necessity is present. Over time, documentation requirements have evolved to support reporting this add-on code in addition to the endoscopic sinus CPT codes whether or not the procedure was a revision surgery.

The American Rhinologic Society recommends the documentation of the following work to support reporting CPT add-on code 61795:

• Pre-op surgical planning including downloading and verifying images
• Registration of data
• Instrument calibration
• Target Registration Error (TRE)
• Anatomic localization and confirmation during surgery
• Documentation of endoscopic approach and intra-operative computer findings.
  
  

Question:
We recently received denials on our allergy testing claims when we linked the diagnosis to chronic rhinitis (472.0) and sinusitis (473.1). Do you have suggestions on how to avoid these denials?

Answer:
First, when reporting services to the payor, the symptom and/or diagnosis that is documented in the medical record is the symptom and/or diagnosis that must be reported with the appropriate CPT code. Research the payors medical policies if they are denying a claim based on the diagnosis. Obtain a waiver or ABN If the only symptom/diagnosis that is documented in the medical record is not listed by the payor as a covered diagnosis. This will allow the practice to transfer the financial responsibility to the patient if the payor denies the service for medical necessity.

Consider using diagnosis codes from the 477.x range for allergy testing as this is a more specific range of diagnoses.

Question:  We are new in Otolaryngology and our Otologist will be performing Canalith Repositioning or Epley Maneuvers. We have been told we have to use an unlisted procedure code and wanted to verify this is correct.

Answer: Good timing and Good News!  You no longer have to report an unlisted procedure code because CPT introduced a new CPT code in 2009.  The new CPT code  is 95992, Canalith repositioning procedure(s) (eg. Epley maneuver, Semont maneuver), per day.   Medicare has assigned 1.13 RVUs in the office and 1.02 RVUs in the facility setting. 

Question: I coded an operative note and because it seems like a lot of CPT codes, I want to make sure they are all reportable.  Can we report 31267, 31287, 31255, 30520, 30140 and 76000 all together or are there bundling issues?

Answer: The response to this question is not based on a review of an operative note, thus we assume the CPT codes represent services documented that all procedures were medically necessary.  With the exception of CPT code 76000 Fluoroscopy (separate procedure), up to one hour of physician time, other than 71023 or 71034 (e.g. cardiac fluoroscopy) all documented services are reported.  Intra-operative fluoroscopy for guidance during a surgical otolaryngic procedure is not separately reportable.  List the procedures in RVU on your claim.

                                  RVUs

30520                         15.03              Septoplasty or submucous resection,

                                                         with or without cartilage scoring,

                                                         contouring or replacement with graft

31255-51                   10.86             Nasal/sinus endoscopy, surgical; with

ethmoidectomy, total (anterior and posterior)

30140-51                   10.67              Submucous resection inferior

                                                turbinate, partial or complete, any method

31267-51                    8.57               Nasal/sinus endoscopy, surgical,

                                                      with maxillary antrostomy; with  

                                               removal of tissue from maxillary sinus

31287-51                   6.25              Nasal/sinus endoscopy, surgical,

                                                        with sphenoidotomy