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The Otolaryngology Coding Coach 2010 Archives

Diagnosis Code

December 23, 2010

Question:  

I evaluated and developed an allergy treatment plan for a patient with allergic rhinitis.  The allergy injections are working.  Do I continue to use the allergic rhinitis as the diagnosis code?

Answer:

Yes, the reason for the visit is the evaluation of the patient’s response to therapy for the condition of allergic rhinitis. While the therapy is working, the reason for the visit is allergic rhinitis and remains the appropriate diagnosis code. 

CPT Makes Way for Reporting Selective Neck Dissections (SND)

December 10, 2010

Question:  

The Head and Neck surgeon in our practice documented that she performed a selective neck dissection. She wants to report CPT code 38724, modified radical neck dissection for this procedure. Is she correct?

Answer:

Your timing is impeccable. There has been much back and forth on this topic for some time and CPT published an article on Neck Dissection Coding in the August 2010 CPT Assistant. 

The article identifies the Selective Neck Dissection (SND) as :”Removal of a subset of lymph node groups (levels) routinely removed in a Radical Neck Dissection (RND) or Modified Radical Neck Dissection (MRND).   SND typically preserves nonlymphatic structures ( SAN, SCM and IJV)* but may also include their sacrifice.  While code 38700 is properly used to code the very limited SHND involving Level 1 only, all other SND’s are reported with CPT code 38724, Cervical lymphadenectomy (modified radical neck dissection)”

The article goes on to address Extended Neck Dissections as “removal of one or more lymph node groups outside of the territories described in the full article (all levels ) or removal of nonlymphatic structures not encompassed by RND, MRND or both.”

CPT Assistant gives an example of an Extended Neck Dissection which may qualify for CPT code 38700 with a modifier 22 or 28724 with a modifier 22.  The article define an example as“the excision of deep cervical musculature, digastrics muscle or involved cranial nerves.”

*Abbreviation Definitions

SAN= Spinal Accessory Nerve

SCM=Sternocleidomastoid Muscle

IJV=Internal Jugular Vein.

S Codes

November 24, 2010

Question:  

What is an S code and when can I use them? I recently read about the use of S2342 Nasal Endoscopy For Post-operative Debridement Following Functional Endoscopic Sinus Surgery, Nasal And/or Sinus Cavity(s), Unilateral Or Bilateral. I have always reported 31237. Should I be using the S Code instead?

Answer:

S codes are temporary third level HCPCS codes and are not recognized by Medicare. The correct code according to CPT is 31237 Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement (separate procedure). 

Do not use an S code unless you have specific instructions from a payor.  Think of these like Medicare G codes.  Medicare G codes are Medicare specific and are only reported to Medicare unless a payor so instructs you to use.  Code accurately according to CPT and only use temporary codes to the specific payors based on your contracts and payor instructions.  If the procedure you are performing does not have a CPT code, use an unlisted according to the CPT rules and Medicare, since Medicare does not recognize the S codes.

Diagnosis Code

November 12, 2010

Question:  

I evaluated and developed an allergy treatment plan for a patient with allergic rhinitis.  The allergy injections are working.  Do I continue to use the allergic rhinitis as the diagnosis code?

Answer:

Yes, the reason for the visit is the evaluation of the patient’s response to therapy for the condition of allergic rhinitis. While the therapy is working, the reason for the visit is allergic rhinitis and remains the appropriate diagnosis code. 

Use of Modifiers

October 29, 2010

Question:  

I was recently told that when applying more than one modifier, they should be listed in descending order. For example, list modifier 59 first, then modifier 50.  Is this correct?

Answer:

Thanks for seeking clarification. Sometimes the rules and recommendations get confusing.

When submitting surgical procedures, it is correct to submit modifiers in descending value order. However there’s another rule to guide the order of modifiers. When CPT codes require multiple modifiers, the modifier that best differentiates the service or protects reimbursement should be first and other modifiers follow in order of sequencing.  For example, if you are reporting services for an Assistant Surgeon, Modifier 80, 81, or 82 will always be the first modifier added to the Assistant Surgeon’s surgical CPT code (s).  Modifier 50 or 59 would be added as the second modifier, only if appropriate. While in this example the numerically larger modifier is listed first, the sequencing is based on modifier definition, not based on numeric value.

 

The concept of modifier 50 and 59 can be confusing in themselves. So let’s take a look at some examples with other modifiers.  

For example:

A patient is seen for evaluation of a new skin lesion on the scalp while in the post-operative period of tympanoplasty.  The otolaryngologist evaluates the patient’s new problem and decides to shave the lesion.  The surgeon documents shaving of 1.0 cm dermal lesion of the scalp.  In this scenario, you would report:

  • 992xx-24, 25 for the E&M service 
  • 11306-79 dermal shaving of the scalp lesion
  • Modifier 24  is required to indicate the E&M is unrelated to the global period of the tympanoplasty.
  • Modifier 25 is required to indicate the E&M is the significant separate E&M service on the same day as the minor procedure.
  • Modifier 79 is added to the surgical procedure to indicate the shaving of the dermal lesion is unrelated to the ear surgery.   

Note, in the E&M example, Modifier 24, the "smaller" numeric modifier is listed first because it is necessary to first bypass the payer’s post-operative global period edit.

Suture Removal

October 14, 2010

Question:  

We had a patient present to our office a week after having a laceration repaired in an outside  ER.  Our surgeon did not see the patient in the ER.   The surgeon removed the sutures (7 days after the injury) in the office.  We have never seen this patient before and had no history on this patient.   He wants to know how to bill for this, and we cannot find a code that does not include anesthesia (15850 and 15851). 

Answer:

Wound repair codes have a ten day global period, thus the removal of the sutures is occurring within the global period for the doctor who performed the repair and not your physician.  Since there was no official of transfer of care to your physician, the patient was not returned to the OR, the suture removal is part of the new patient E&M service.

Removal of Tube in Office

September 30, 2010

Question:  

How do I code for the removal of ventilation tubes when performed in the office setting?


Answer:

There is no separate CPT code for this activity so it is part of your E&M service.  It is not appropriate to report 69200 (Removal foreign body from external auditory canal; without general anesthesia) or 69424 (Ventilating tube removal requiring general anesthesia).


Drainage of Seroma in the OR

September 16, 2010

Question:  

Our surgeon returned a patient to the OR for the drainage of a seroma and drain placement 2 weeks after a total parotidectomy.   How do I code for the drainage of the seroma and drain placement?

Answer:

There is no CPT code for the placement of the drain associated with the seroma drainage.

Look at CPT code 10140, Incision and drainage of hematoma, seroma or fluid collection as a code option based on the surgeon’s documentation.  The placement of the drain is inherent to the drainage procedure and not separately reportable.

Append modifier 78 to the appropriate surgical procedure as the patient is in the global period of the parotidectomy.

Endoscopic Zenker’s Diverticulum

September 2, 2010


Question:

How do I code for removal of a Zenker’s diverticulum when the procedure was performed endoscopically? Can I still use 43130 (Diverticulectomy of hypopharynx or esophagus, with or without myotomy; cervical approach)?

Answer:

There is no code for the endoscopic removal of the Zenker's diverticulum as 43130 describes an open procedure.  You will need to use an unlisted procedure code such as 43499 (Unlisted procedure, esophagus).

E&M Visit with Allergy Injection

August 19, 2010


Question:

Can I bill for both the 99211 and “95117-Professional services for allergen immunotherapy not including provision of allergenic extracts; 2 or more injections” – codes when patients come for a weekly allergy injection?

Answer:

If the purpose of the visit is to provide the allergy injection then report only the code for the allergy injection (eg, 95115, 95117).  If you provide a significantly, separately identifiable E&M service then you may separately report that with 9921x and append modifier 25 to the E&M code.  Be sure you have good documentation of the separate E&M service and can support the medical necessity of this additional charge.

Endoscopic Sinus Surgery and Nasal Polypectomy

August 5, 2010

Question:

Our surgeon recently performed a nasal sinus endoscopy with removal of tissue from the maxillary sinus and a nasal polypectomy. The payor paid for CPT code 31267 (maxillary sinus) but denied the polypectomy (31237).  Did we code this correctly and should we appeal?

Answer:

Without the entire operative note it is difficult to answer the question specifically, but let’s talk about the combination of procedures.

Report CPT code 31267(Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus) when the surgeon’s documentation includes:

  • Use of endoscope for surgical approach
  • Documentation of entrance into the maxillary sinus (past the osteomeatal complex)
  • Removal of tissue from within the sinus

Do not report CPT code 31237 (Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement (separate procedure)) for the removal of nasal polyps, if the nasal polyps are removed from the same side of the nasal cavity where the endoscopic sinus procedure is performed.   CPT code 31237 is a “separate procedure” code, so is included in more extensive endoscopic sinus surgery, when on the same-side of the nasal cavity. 

Do not appeal CPT code 31237, if the scenario described in your question is answered in our response. Instead write it off as a coding error adjustment, and use the denial as a coding education opportunity.


G0268 or Not?

July 22, 2010

Question:

Our otologist employs an oto tech, who has received formal training by the AAOHNS and is supervised in the office by the otologist.   After several months of training, the otologist is allowing the oto tech to perform tympanograms and report the services under the otologist.   We have recently had several patients who had to have impacted cerumen removed by the otologist prior to the tympanogram being performed.   Do we need to report the cerumen impaction with CPT code 69210 or G0268?

Answer:

This is a good question and the answer may vary by individual Medicare carriers. Because both services are billed under the otologist’s NPI, it may be necessary to use the G0268 code to indicate that the otologist removed the impacted cerumen, and the ototech performed the tympanogram.  Some Medicare carriers may reimburse both the tympanogram and the removal of impacted cerumen using 69210.   A tympanogram falls within the definition of audiologic testing, thus the G code may be necessary.

Non-Physician Provider Billing During the Global Period

July 8, 2010


Question:

Our otolaryngologist recently employed a nurse practitioner (NP) in the office. The NP is seeing patients on rounds in the hospital, and she recently submitted a charge for a 99232 on a Medicare patient who was post-op for a total laryngectomy. The documentation for the visit all pertained to the laryngectomy. Can she report this E&M service when the patient is in a global period? She says yes, because she did not assist and is not in a global period.

Answer:

Great question and one of increasing concern as it relates to one of many issues related to Non- Physician Provider billing. We appreciate your attentiveness and raising the question.  While the NP was not involved in the surgery, she is employed by the surgeon who performed the surgery; thus all visits related to the surgical procedure are included in the global period, and not reportable whether performed by the surgeon or the NP. If the visit was for an unrelated problem that was evaluated and managed, the service would be reportable by the surgeon or the NP, and a modifier 24 would be appended to the E&M, and the appropriate unrelated diagnosis linked to the E&M.

Soft Tissue Tumor Codes and Wound Closures

June 24, 2010


Question:

Our surgeon is performing a complex closure for a procedure defined by one of the new soft tissue tumor codes.  Our surgeon believes reporting complex closure in addition to the surgical resection is correct.   We would like to verify this. And if so, does that mean any surgical procedure requiring a complicated closure is billed separately?

Answer:

The introduction of the new and revised soft tissue tumor codes, found in the Musculoskeletal section of the CPT book have very specific coding guidelines.   According to CPT 2010,”Extensive undermining or other techniques to close a defect created by skin excision may require a complex repair which may be reported separately. Dissection or elevation of tissue planes to permit resection of the tumor is included in the excision.”

According to this definition, if a complex closure is required and is performed for reasons other than closure secondary to elevation of the tissue planes, the complex closure may be reported in addition to the surgical procedure.

It is important to read the Guideline Sections for each range of CPT codes. Typically the normal/usual closure is included in a surgical procedure, thus not typically reported unless a distant flap, graft or secondary closure is required.  There are also specific coding guidelines related to the Excision of Skin lesions (114xx, 116xx) that are again unique to surgical procedures defined by these ranges of codes.  

Example

A surgeon performs a radical resection of a 5.5 cm (including margins) malignant neoplasm of the neck and a 10 cm complex closure of the wound.  Assuming medical necessity of the closure other than that necessitated by the dissection/elevation of the tissue planes, the surgeon may report the both the radical resection and the complex closure

Based on the example, the following CPT codes are reportable:

21558  Radical resection of tumor (e.g., malignant neoplasm), soft tissue of neck or anterior thorax; 5 cm or greater
13132-51*  Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 2.6 cm to 7.5 cm
13133 Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; each additional 5 cm or less (List separately in addition to code for primary procedure)

*Note: According to CPT rules modifier 51 is the most appropriate modifier.  Medicare has a CCI edit in place bundling the repair into the resection code, thus a modifier 59 will be required.

Removal of Gastrostomy Tube

June 10, 2010

Question:

Is there a CPT code for the removal of a gastrostomy tube?

Answer:

There is not a specific code for the removal of a gastrostomy code.   Let’s look at a couple of scenarios.

In the office, during the global period—report 99024

In the office, outside the global period, report 9921x

If the patient is returned to the OR and the tube is removed and the gastrostomy site is surgically closed, report 43870, Closure of gastrostomy, surgical.

Intranasal Biopsy Using a Zero Degree Scope

May 27, 2010

Question:

Our surgeon performed an intranasal biopsy using a zero degree scope? Do I use CPT code 30100  to report this procedure?

Answer:

No, CPT code 30100 is used to report an “excision” and is not found in the endoscopic section of CPT.  Do not report 30100 if the biopsy is performed endoscopically.   Use CPT code 31237 Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement (separate procedure) for an endoscopic nasal biopsy.

Nasopharyngeal Biopsy With Direct Laryngoscopy

May 13, 2010


Question:

Our surgeon performed a fiberoptic laryngoscopy to evaluate the patient’s response to voice therapy and found a nasopharyngeal mass.  The surgeon took the patient to the OR for a direct laryngoscopy, vocal cord stripping, and a nasopharyngeal biopsy.   Can I code the nasopharyngeal biopsy in addition to the direct laryngoscopy or is it included as part of the approach?

Answer:

The nasopharyngeal biopsy is separately reportable. A direct laryngoscopy (unlike a fiberoptic laryngoscopy) does not include any work in or examination of the nasopharynx.  Report the vocal cord stripping with CPT 31540 or 31541.  Use 31541 if the operating microscope was used, use 31540 if no microscope or telescope was used to perform the vocal cord stripping.   It appears the nasopharyngeal lesion was visible, thus CPT code 42804 may be the most appropriate because it is used to report a biopsy of the nasopharynx, for a visible simple lesion.   Append modifier 51 to the nasopharyngeal biopsy CPT code as this code has less RVU value than the vocal cord stripping CPT codes.


Computerized Hearing Testing

April 29, 2010

Question:

We are starting to do a hearing test called an “otogram”.  How do we code this?

Answer:

Historically there has not been a CPT code to describe services of automated or computer-assisted hearing tests so reporting an unlisted code such as 92700 was appropriate. 

However, effective 1/1/10 there are new Category III CPT codes for these services.  The codes 0208T-0212T now describe automated/computer-assisted hearing tests.

The AMA website includes the following information:

In addition to the revision of code 0199T and addition of Category III codes listed above, codes 0208T-0222T were accepted at the June 2009 CPT Editorial Panel meeting for the 2011 CPT production cycle. Therefore, these codes will not appear in the 2010 CPT codebook. However, due to the Category III code early release policy, these codes are effective on January 1, 2010, following the six month implementation period which begins July 1, 2009.

 

0208T Pure tone audiometry (threshold), automated (includes use of computer-assisted device); air only

Released July 1, 2009
Implemented Jan 1, 2010

0209T     Air and bone

Released July 1, 2009
Implemented Jan 1, 2010

0210T Speech audiometry threshold, automated (includes use of computer-assisted device); Released July 1, 2009
Implemented Jan 1, 2010
0211T     With speech recognition Released July 1, 2009
Implemented Jan 1, 2010
0212T Comprehensive audiometry threshold evaluation and speech recognition (0209T, 0211T combined), automated (includes use of computer-assisted device) Released July 1, 2009
Implemented Jan 1, 2010
(For audiometric testing using audiometers performed manually by a qualified health care professional, see 92551-92557) Implemented Jan 1, 2010


Source:  http://www.ama-assn.org/ama1/pub/upload/mm/362/cptcat3codes.pdf


Claim Form Submission for Modifier 50

April 15, 2010


Question:

One of my doctors lists his endoscopic sinus surgery codes as individual codes (31254, 31254-50, 31256-51, 31256-50) but one of my other doctors lists his codes together (31254-50, 31256-50).  Which way should I bill?

Answer:

The claims submission format for bilateral procedures varies by payer.  Medicare wants the codes on one line or in a “bundled” or “single line” format.  So you’d submit 31255-50 with 1 unit and double your fee.  Some other payors may recognize this as two procedures and pay appropriately, like Medicare.

Other payors (usually non-Medicare), will only recognize a bilateral procedure if entered on two lines. For example: 31255 1 unit, 31255-50 1 unit, 31267-51 1 unit, 31267-50 1 unit.  This is called the “line item” format. 

You will want to survey your payors to see which format each wants for bilateral procedures. If you don’t know, we recommend the line item format to ensure you receive appropriate reimbursement for bilateral procedures.

Consultation Codes

April 1, 2010

Question:

What’s the deal – I heard the consultation codes have been deleted in 2010!  How can they do this?

  

 Answer:

Hold on….the consultation codes have not been deleted.  These codes (9924x for office or other outpatient consultations and 9925x for inpatient consultations) still exist in CPT.  Here’s what has changed: Medicare, as a payer, for the Part B program only has chosen not to reimburse providers for the consultation codes in 2010.  The vast majority of other payers have not stopped paying for consultation codes in 2010. Typically they will notify you if they are going to change their policy. For example, United Healthcare released the following statement:

 

For UnitedHealthcare commercial plans, there will be no change in reimbursement for CPT codes 99241-99245 and 99251-99255 at this time.  Physicians may continue to submit claims for these services, and will be reimbursed according to UnitedHealthcare payment policies. 

 

"For UnitedHealthcare Medicare Solutions, including SecureHorizons®, AARP® MedicareComplete®, Evercare®, and AmeriChoice® Medicare Advantage benefit plans, these plans will follow CMS regulations and implement the change, effective January 1, 2010. The change also includes the revalued relative-value units (RVUs) for E&M CPT codes and a new coding edit, consistent with CMS, to deny the CPT consult code as a non-covered service."

 

For AmeriChoice Medicaid plans that follow Medicare rules for their fee schedules, AmeriChoice will be aligning with CMS rules and implemented the change effective January 1, 2010.  For all other Medicaid states, AmeriChoice will follow the UnitedHealthcare commercial position and continue to pay for the consult codes, until directed otherwise by a state to pursue other strategies.”

  

Note that Medicare issued their change in payment policy for the Part B program.  It appears that many Medicare Advantage plans (Part C) will be adapting the same policy.  We’ve even heard that some Medicaid carriers are doing the same.

  

For more information on Medicare’s policy, refer to Transmittal 1875, as well as the corresponding MedLearn Matters article.

What is the Global Period for Using Modifier 76

March 18, 2010

Question:

What is the time period for a modifier 76?  We did sinus surgery on a patient several years ago and we are having to repeat some of the surgery.  Should I use a modifier 76?

  

Answer:

Modifier 76 is appended to the same CPT code(s) when performed in that code(s) postoperative global period. So the most number of days that it might apply is 90 but, again, it depends on the CPT code originally billed. Since the patient had several years ago, you do not need a modifier associated with a global period. 

New Audiologic Function Test Codes
March 4, 2010


Question:


I notice some new codes in the 2010 CPT book but am having trouble figuring out how to use them. Can you please help?


Answer:


Sure! The new code, 92550 (Tympanometry and reflex threshold measurements) represents the combined services of existing codes 92567 and 92568. So when both typanometry and acoustic reflex testing is performed, the new or “combined” code of 92550 should be reported. If either 92567 (Tympanometry, impedance testing) or 92568 (Acoustic reflex testing, threshold) is performed alone then report the individual code performed. It is not appropriate to report 92550 with 92567 or 92568.

The same is true for the new “combined” code 92570 (Acoustic immittance testing, includes tympanometry (impedance testing), acoustic reflex threshold testing, and acoustic reflex decay testing). CPT 92570 represents the combined services of existing codes 92567 and 92568 as well as deleted code 92569 (Acoustic reflex testing; decay). Again, if either 92567 or 92568 are performed alone then report the individual code performed. It is not appropriate to report 92570 with 92567 or 92568. Remember, 92569 (Acoustic reflex testing; decay), was deleted in 2010.

Sublingual Allergy Therapy

February 18, 2010


Question:

How do we bill for sublingual drops as an allergy treatment?

  

 Answer:

There is no CPT code for this activity (sublingual immunotherapy or SLIT) so you would use an unlisted code such as 95199.  However, we recommend you check with your payors for coverage.  Many insurance companies, including Medicare, consider it “investigational” and will not reimburse for sublingual allergy immunotherapy. The Joint Council of Allergy, Asthma and Immunology (JCAAI) and the American Academy of Otolaryngology-Head and Neck Surgery have “jointly agreed not to request a CPT code for SLIT at this time, since [they] do not believe that the evidence to support the application for such a code currently exists in the United States”.

Typically this is a service that is non-covered by the payor and for which you would collect cash from the patient.

What is included in CPT code 92540?

February 4, 2010

Question:

Can you explain when I would use the new CPT code 92540 when doing an ENG?

  

 Answer:

Sure!  CPT 92540 is: Basic vestibular evaluation, includes spontaneous nystagmus test with eccentric gaze fixation nystagmus, with recording, positional nystagmus test, minimum of 4 positions, with recording, optokinetic nystagmus test, bidirectional foveal and peripheral stimulation, with recording, and oscillating tracking test, with recording.

This new code includes four component codes: 92541 (spontaneous nystagmus), 92542 (positional nystagmus), 92544 (optokinetic nystagmus), and 92545 (oscillating tracking).  Do not report 92540 with any of the component codes.  However, 92540 may be separately reported with 92543 (calorics).   

Intranasal Biopsy Using a Zero Degree Scope?

January 21, 2010

Intranasal Biopsy Using a Zero Degree Scope?


Question:

Our surgeon performed an intranasal biopsy using a zero degree scope? Do I use CPT code 30100  to report this procedure?

  

  

Answer:

No, CPT code 30100 is used to report an “excision” and is not found in the endoscopic section of CPT.  Do not report 30100 if the biopsy is performed endoscopically.   Use CPT code 31237 Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement (separate procedure) for an endoscopic nasal biopsy.

Is Insertion of a Drain Reportable?

January 7, 2010

Nasopharyngeal Biopsy


Question:

Our surgeon performed a fiberoptic laryngoscopy in the office to evaluate the patient’s response to voice therapy and found a nasopharyngeal mass.  A week later, the surgeon took the patient to the OR for a direct laryngoscopy, vocal cord stripping, and a nasopharyngeal biopsy.   Can I code the nasopharyngeal biopsy in addition to the direct laryngoscopy or is it included as part of the approach?   

  

Answer:

The nasopharyngeal biopsy is separately reportable. A direct laryngoscopy (unlike a fiberoptic laryngoscopy) does not include any work in or examination of the nasopharynx.  Report the vocal cord stripping with CPT 31540 or 31541.  Use 31541 if the operating microscope was used, use 31540 if no microscope or telescope was used to perform the vocal cord stripping.   It appears the nasopharyngeal lesion was visible, thus CPT code 42804 may be the most appropriate because it is used to report a biopsy of the nasopharynx, for a visible simple lesion.   Append modifier 51 to the nasopharyngeal biopsy CPT code as this code has less RVU value than the vocal cord stripping CPT codes.

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