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The Otolaryngology Coding Coach 2012 Archives

Ear Canal Debridement

December 27, 2012

Question:  

What CPT code would I use for a debridement of purulent debris from, with or without placement of a wick in, the ear canal such as when the patient has Swimmer’s ear?

Answer:

There is no CPT code for this activity and it would be considered part of the E&M code for your service that day. However, if you used the microscope for the diagnosis and treatment then you could also report 92504 (Binocular microscopy (separate diagnostic procedure)).

Allergy Injection Supervision Requirements

December 13, 2012

Question:  

Does the physician have to be in the building when giving an allergy injection? Or can the allergy injection be supervised by physician assistant?

Answer:

Medicare’s physician supervision guidelines for incident to billing require the billing provider to be physically present in the office suite whether it is a physician or physician assistant (or even a nurse practitioner for that matter). Medicare’s will reimburse at 100% of the physician fee schedule when a physician is the billing/supervising provider and at 85% of the physician allowable when the PA or NP is the billing/supervising provider. You’ll want to check with you other payors for their guidelines.

Removal of Nasal Pack

November 29, 2012

Question:  

The emergency room physician put an anterior nasal pack in a patient and instructed him to see me the next day because I was the ENT physician on call. I saw the patient and removed the pack. I can’t find a CPT code for pack removal – what do I bill?

Answer:

You’re right, there is no CPT code for removal of nasal packing because the packing placement code(s) include necessary removal. Removing the nasal pack is included in your E&M code or in CPT 31231 (Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure)) if you happen to also use nasal endoscopy to assess the nasal cavity.

Allergy Injection

November 15, 2012

Question:  

We have a patient that brings in her own allergy immunotherapy serum that another doctor mixed for her and we just give her the injection. We are told to bill 96372 (Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular) for the injection. Is that correct?

Answer:

Actually, you would report 95115 (Professional services for allergen immunotherapy not including provision of allergenic extracts; single injection) as this code specifically describes an allergy immunotherapy injection. Use 95117 (Professional services for allergen immunotherapy not including provision of allergenic extracts; 2 or more injections) if you give 2 or more injections.

Myringoplasty and Fat Graft

November 1, 2012

Question:  

Can we bill 15770 with 69620 for a myringoplasty with fat graft?

Answer:

First, CPT describes 15770 as Graft, derma-fat-fascia meaning it is a graft that includes three layers of tissue. The procedure you describe says “fat graft” so 15770 is not accurate since fat is only one layer of tissue.

CPT 69620 states Myringoplasty (surgery confined to drumhead and donor area) so it includes obtaining the donor graft. Therefore, a myringoplasty with fat graft is reported using only one code, 69620.

New or Established Patient

October 18, 2012

Question:  

I am new to Otolaryngology. I am in a practice that employs a neuro-otologist and a rhinologist in addition to general otolaryngologists. Do the new patient rules apply to each of these specialties? For example, a patient is first seen by the general otolaryngologist and then is sent to the neuro otologist. Can the neuro-otologist bill a new patient visit because he is a different specialty.

Answer:

Welcome to the world of Otolaryngology. Your question is a good one. Medicare defines the specialty designations and the only specialty designated for your practice is Otolaryngology. So while they are subspecialists, they practice within the Otolaryngology specialty according to Medicare. In your scenario, the neuro-otologist will report an established patient visit if the patient is seen within 3 years.

Le Fort Fractures

October 4, 2012

Question:  

I performed open reduction internal fixation of bilateral Le Fort II fractures through multiple approaches. Would this be coded as 21347-50? Otherwise asked, does 21347 constitute a repair of a unilateral Le Fort fracture?

Answer:

The Le Fort fracture repair codes should not be reported with the bilateral modifier (50). A Le Fort fracture is inherently bilateral; therefore, the repair procedure (and CPT code) is also inherently bilateral.

Removal of Tube in Office

September 20, 2012

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).

Tonsils / UPPP Revisited

September 6, 2012

Question:  

I was recently speaking to a colleague about reporting CPT codes 42826 and 42145 together when both a tonsillectomy and UPPP are performed. My colleague said they should be reported together when performed but when I looked at the CCI edits they are bundled. I told her that I could not report both codes because of the CCI edit. She disagreed and said I should report both if performed. Now, I am confused and unsure how I should report this if both services are performed at the same setting.

Answer:

We certainly understand your dilemma. In this scenario we agree with your friend. The following is a response to the same question posted in the AMA CPT Assistant in August 1997.

“AMA Comment

From a CPT coding perspective, the tonsillectomy is a separate and distinct procedure. Therefore, if the physician performs a palato-pharyngoplasty and a tonsillectomy, both services would be reported. In this instance, the modifier -51 should be appended to the secondary or additional procedure to indicate that multiple procedures were performed on the same day or at the same surgical session by the same physician”

Remember, the coding rules are written by the American Medical Association while Medicare CCI edits are payment rules for Part B Medicare. Medicare does not include every possible code combination in the CCI edits, thus you could actually code incorrectly if you only reported services based on Medicare CCI edits.

CCI edits are created and reversed each quarter, thus trying to code accurately based on CCI would be challenging. KZA and the AAOHNS recommend reporting services based on the AMA CPT rules to ensure coding compliance and accurate reporting of services.

30930 and 30140

August 23, 2012


Question:  

Our surgeon wants to report CPT code 30930 every time he does an turbinate outfracture with his submucous resections (30140). I have explained that the outfracture is included but he disagrees. I talked to a peer in another practice and he told me that I can’t report it because there is a CCI edit in place. We code according to CPT rules, not Medicare payment rules, thus I would never use that as rationale in explaining to the surgeon why a code set is reportable together or not. Can KZA help with an explanation?

Answer:

Great question and thanks for reaching out to the Otolaryngology Coding Team. We checked with the team and our response follows.

In 2006, CPT revised the definition of CPT code of the turbinate codes to identify surgical procedures on the inferior turbinates only. According to a citation in the CPT Changes: An Insider’s View, “CPT codes 30130, 30140, 30801, 30802, and 30930 have been revised to clarify their widespread usage specific to the inferior turbinates and primary reporting for procedures performed for the treatment of inferior turbinate hypertrophy causing nasal airway obstruction and to eliminate frequent confusion with middle and superior turbinates when other intra-nasal surgeries (e.g., endoscopic sinus surgery) are performed.”

Additionally, codes 30801, 30802, and 30930 were revised with the removal of “separate procedure” from the descriptors. Cross-references were added in support of these revisions to indicate codes 30130 (partial or complete excision of turbinate bone) and 30140 (partial or complete submucous resection of turbinate bone), which report larger procedures for which removal of the inferior turbinates are inherent, would not be appropriately reported in conjunction with these codes.” As a result of this rule change when the codes were revised to specifically address surgery on the “inferior” turbinates, the procedures became inclusive to each other.

Finally, the CPT guidelines listed directly underneath 30930 state “(Do not report 30801, 30802, 30930 in conjunction with 30130 or 30140)”. Therefore, it is not appropriate to report 30930 with 30140 ever for procedures on the same turbinate.

Just because there is a Medicare CCI column edit of “1” doesn’t mean it is appropriate to report both codes. You must understand CPT coding rules first.

Removal of Tube in Office

August 9, 2012

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).

Endoscopic Zenker's Diverticulum

July 26, 2012


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

July 12, 2012


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 the patient comes for their 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 (e.g., 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.

Ear Exam Under Anesthesia

June 28, 2012


Question:  

Our surgeon performed an evaluation of the external ear canal on a pediatric patient because the child would not allow the surgeon to evaluate the ears thoroughly in the office. We cannot find a CPT code for this service. Do we use an unlisted code?

Answer:

The correct way to report this service, assuming a more definitive procedure was not performed is CPT code 92502-52. CPT code 92502, (Otolaryngologic examination under general anesthesia) describes a complete ENT exam, thus modifier 52 (reduced services) is appropriate to indicate an entire otolaryngologic examination was not performed.

Wound Cultures

June 14, 2012

Question:  

Our surgeon recently took a patient to the OR for an I&D of a neck abscess. The documentation in the operative note indicates a culture was taken. The only CPT codes I can find are in the pathology section. Is this work reportable by the surgeon?

Answer:

Thanks for your question and one that is not uncommon. The work associated with obtaining the culture is included in the more extensive surgical procedure for the I&D.

Written Physician Order for Audiologic Evaluations?

May 31, 2012

Question:  

Does Medicare require a written physician order for audiologic evaluations, even if the audiologist is employed by our otolaryngology practice?

Answer:

Yes. Medicare requires the following in order to file under the NPI of the audiologist for diagnostic audiology procedures, as specified in the Medicare Benefit Policy Manual, Chapter 15:

a. The order must be “for the purpose of obtaining information necessary for the physician’s diagnostic medical evaluation or to determine the appropriate medical or surgical treatment of a hearing deficit or related medical problem.”

b. “The reason for the test should be documented either on the order, on the audiological evaluation report, or in the patient’s medical record.”

c. “Documentation should indicate that the test was ordered, that the reason for the test results in coverage, and that the test was furnished to the patient by a qualified individual.”

d. Orders may be a “written document, signed by the physician, hand-delivered, mailed or faxed; a telephone call or e-mail placed by the treating physician” to the audiologist.

Chapter 15 adds that both the referring physician (who could be an offsite physician, e.g., a primary care physician or neurologist) and the audiologist must have telephone referrals documented in their respective charts.

Make sure your EMR makes documentation easy!

Medicare Supervision Requirements for Audiologic Diagnostic Testing

May 17, 2012

Question:  

We would like to maximize the time the audiologist sees patients in the office when the otolaryngologist is in surgery. Is the physician required to be in the office for the supervision of any diagnostic testing when the audiologist is here alone and performing diagnostic hearing tests on Medicare patients?

Answer:

No. Per Medicare supervisions requirements (CMS MM6447), when performed by an audiologist, the direct supervision requirement is not applicable to diagnostic audiology procedures. The audiologist may see any patient, but remember, the physician referral for a medically necessary reason for Medicare beneficiaries is required.

CPT and Diagnosis Codes for a Skin Lesion

May 3, 2012

Question:  

A patient was sent to us by another provider who had a biopsy proven pathology report showing a basal cell carcinoma. We removed additional margins and the pathology report came back benign for us. We are confused about whether we should report the CPT and diagnosis codes for a malignant or benign lesion since we did not do the original biopsy.

Answer:

This is a very good question! Because you have a previous positive pathology report, even though it is from a different physician, then you may report your procedure using the excision of malignant lesion CPT code (e.g., 116xx) and a malignant skin neoplasm diagnosis code.

Selective Debridement of the Skin - How is it coded?

April 12, 2012


Question:  

The debridement codes for skin, 11040 and 11041 are no longer in the CPT book. Does that mean debridement of the skin is no longer billable?

Answer:

The selective debridement codes were revised in 2011. CPT 11040 and 11041, previously used for debridement of partial and full thickness skin respectively, have been deleted. To report selective debridement of the skin, use 97597 and 97598.

New descriptions of the other debridement codes advise reporting 11042 for debridement of subcutaneous tissue, 11043 for muscle and/or fascia, and 11044 for bone. Also new in 2011, these codes are reported by size of debridement and have add-on codes for additional square centimeters debrided. Refer to the CPT Manual for a complete description of the appropriate use of these new/revised codes.

Coding Multiple Z-Plasties

March 29, 2012

Question:  

When billing for multiple Z-plasties, is the billing done by the number of Z-plasties or the total sq cm having added together each of the Z-plasty areas in sq cm?

Answer:

The coding for a Z-plasty (140xx codes) is done based on the total sq cm of the primary and secondary defect size and not necessarily the number of z-plasties done. So you will report one code for each defect. If there are two separate defects closed with two separate advancement flaps report one 140xx code for each defect – or two codes.

Different Procedures / Different Ears

March 15, 2012

Question:  

We did bilateral myringotomy and tubes with removal of left myringotomy with paper patch graft.  I know the two codes, 69436 and 69610, can’t be billed together. But can I bill 69436-RT with 69610-LT?

Answer:

Absolutely!  We suggest you also include modifier 59 (distinct procedural service) on 69610 as many payors do not recognize the RT (right) and LT (left) modifiers. CPT 69610 has the higher value so it will be reported first (69610-LT and 69436-59, RT).

Medicare Supervision Requirements for Audiologists

March 1, 2012

Question:  

We would like to maximize the time the audiologist sees patients in the office when the otolaryngologist is in surgery. Is the physician required to be in the office for the supervision of any procedures when the audiologist is here alone when they see any Medicare patients?

Answer:

No. Per Medicare supervision requirements (CMS MM6447), when performed by an audiologist, the direct supervision requirement is not applicable to diagnostic audiology procedures. The audiologist may see any patient, but remember, the physician referral for a medically necessary reason for Medicare beneficiaries is required.

I&D in the Office During the Global Period

February 16, 2012

Question:  

Our surgeon saw a patient in the office for a routine post-op check during the global period of a thyroidectomy. During the visit, the surgeon notes that the patient has some neck fullness and performs an incision and drainage in the office. I have the correct CPT code, but I am wondering if I should use Modifier 58 or 79. I think the correct modifier is modifier 79 because he documents a new diagnosis “chylous effusion”. Do you recommend modifier 58 or 79?

Answer:

The reporting (or not) of this service performed in the office, during the global period will be payor dependent. If the payor is Medicare, or follows Medicare rules, the visit is not reportable as this a complication of the original surgery.

If the payor follows CPT rules, and the surgeon determines this is not “typical postoperative care” then traditionally no modifiers are appended. Modifier 79 is typically reserved for an ‘unrelated’ procedure/ service at a different location. The chyle leak is secondary to the surgical intervention—thus if there had not been surgery, there would not be a chyle leak. Survey your private payors to determine which modifier, if any, is required.

Intranasal Application of Medication

January 26, 2012


Question:  

Our physicians will be starting a new treatment for chronic rhinosinusitis in patients after they have endoscopic sinus surgery and are still symptomatic. As we understand the medication, which is a gel, will be applied in the office under endoscopic visualization to the areas of the sinus mucosa where there inflammation is still present. The physician’ will perform an endoscopic exam and then apply the gel to the sites of inflammation when present.

How do we code for this endoscopic application of the gel?


Answer:

Thanks for your question! We assume you are speaking about the application of Mometasone Furoate gel. There is no code for the endoscopic “application” as the use of the endoscope is the “route” or “vehicle” to administer the drug. The scenario indicates that an endoscopic exam will be performed, thus the use of 31231 appears to be the most appropriate. A definitive CPT code recommendation can only be given once a procedure note is reviewed.

Endoscopic Polypectomy

January 12, 2012


Question:  

Can you tell me why CPT 31237 is bundled into the sinus codes? We performed 31237, to remove the nasal polyps, and then 31254 for the endoscopic anterior ethmoidectomy on the same side. The payor denied 31237 as inclusive to 31254 and I don’t know why.

Answer:

The payor is correct – 31237 is indeed included in 31254 (and the other endoscopic surgical sinusotomy codes) when performed on the same side. Removing nasal polyps is considered “access,” or part of the approach, to the sinuses. The value for the endoscopic sinusotomy codes are valued to include removal of nasal polyps so it is considered “double billing” to also report 31237.

Also, note that the CPT descriptor for 31237 includes the parenthetical statement “separate procedure.” This means that 31237 may be reported if it is the only procedure performed in the area but is included in a “larger” procedure performed at the same time in the same area.

Find more Questions and Answers in the
Otolaryngology Coding Coach Archives
       

Mary LeGrand,
RN, MA, CCS-P, CPC

Kim Pollock,
RN, MBA, CPC

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