92504 Binocular Microscopy

December 14, 2017 Question: I used the microscope to examine both ears during an office visit because the middle ear Otoscopic exam was abnormal.  Can I report 92504 with modifier 50 (bilateral procedures)? Answer: No.  CPT 92504 describes using a microscope for an examination – it represents payment for using a separate piece of equipment…


Dizziness and E/M Code Level

November 16, 2017 Question: When I see an adult new patient with a chief complaint of dizziness, I can automatically code a level 4, 99204, right? Answer: Oh, only if E/M coding were that easy!  Don’t forget, for 99204 you must have medical necessity for and perform a comprehensive History and a comprehensive Exam (8…


Direct Laryngoscopy and Laryngectomy

November 2, 2017 Question: Can I bill 31525 (31526) for a diagnostic laryngoscopy performed at the same operative session as the laryngectomy (31360)?  I do this map out the tumor for the laryngectomy and make sure there are no secondary tumors that may have occurred since I scoped the patient previously. Answer: A diagnostic endoscopy…


Esophagoscopy and Glossectomy

October 19, 2017 Question: Can I bill 43191 for the rigid esophagoscopy (or 43200 for a flexible esophagoscopy) performed at the same operative session as the glossectomy (eg, 41150)? I do this to map out the tumor for removal and make sure there are no other tumors that may have occurred since I saw the…


Abdominal Fat Graft

October 5, 2017 Question: I billed 15770 (Graft; derma-fat-fascia) for an abdominal fat graft.  After reviewing my operative report, the insurance company denied the code saying it was wrong.  What code should I use? Answer: CPT 15770 is a composite graft meaning more all layers – dermis, fat and fascia – are used to repair…


Endoscopic Sphenopalatine Artery Ligation

September 21, 2017 Question: I did an endoscopic ligation of the left sphenopalatine artery for recurrent epistaxis in a patient with Coumadin-induced coagulopathy. I don’t see a CPT code for this procedure – can I use 30920? Answer: No, you’ll need to use an unlisted code such as 30999. Your comparison code can be 30920…


Assistant Surgeon Payments

August 10, 2017 Question: We are seeing payers ask for payment back when we use Modifier 80 for assistant surgeon.  Is there a reason why they would take the payment back? Answer: We are seeing many payers including Medicare and Medicaid ask for payment recovery when the documentation does not explain what role the assistant…


Closure After Moh’s Surgery

July 27, 2017 Question: I did the closure for a patient’s left ear defect after the Moh’s surgeon excised the basal cell carcinoma at the same operative session. I had to remove a little devitalized tissue before closing the wound with a full thickness graft. Can I code both 15260 (full thickness graft) and 11043…


Billing for Pre-Op H&P Visit

July 13, 2017 Question: Hospitals require that we do an H&P within 30 days of taking a patient to the OR. If this visit is more than 48 hours prior to surgery, is that a billable visit? Answer: No, the H&P in this case is not a billable visit.  This question comes up often and…


Facial Nerve Monitoring with Ear Procedures

June 22, 2017 Question: Can I bill for facial nerve monitoring during a cochlear implant or mastoidectomy procedures? Answer: Facial nerve, and any cranial nerve, monitoring is included in the primary procedure code (e.g., cochlear implant, mastoidectomy) for the surgeon and should not be separately reported according to both CPT and Medicare. A completely different…


Tympanoplasty with Middle Ear Exploration

June 8, 2017 Question: I billed 69631-RT for the transcanal tympanoplasty, 20926-RT for the temporalis fascia harvest, and 69440-RT for the middle ear exploration. Should I have used modifier 59 on 69440 because it didn’t get paid? Answer: No! You should not have coded 69440 for exploring the same ear on which you did the…


Billing Medicare Patient Admittance

May 11, 2017 Question: If a Medicare patient has been admitted to the hospital as an inpatient and the patient is transferred to my care in the ED before they are moved to an inpatient bed, do I bill an ED visit or an initial hospital care code when surgery is not planned? Answer: Since the…


Scribe Question

April 27, 2017 Question: In my office, we use a PA as a scribe for new patient office visits for our doctors.  We have an electronic medical record and the scribe signs in under her own name when she begins notating for the doctor.  What is the correct way to notate in the medical record…


Billing “Incident to”

April 13, 2017 Question: Whose NPI number do we bill under when a PA sees the patient in the office under the “incident to” rules for Medicare?  We bill under the NPI number of the physician who is assigned to the PA.  Is that correct? Answer: No, when billing “Incident to,” bill under the NPI…


Assistant Surgeon Payments

March 30, 2017 Question: We are seeing payers ask for payment back when we use Modifier 80 for assistant surgeon. Is there a reason why they would take the payment back? Answer: We are seeing many payers including Medicare and Medicaid ask for payment recovery when the documentation does not explain what role the assistant…


ICD-10-CM for Sinusitis

March 16, 2017 Question: We are having a discussion in the office about the correct way to code chronic sinusitis of multiple sinuses in our office. Some are saying to code each sinus condition separately as they have specific codes for each one, some say to code with the “other code”. Who is correct? Answer:…


Pap Nap Coding

March 2, 2017 Question: How would you code for a pap nap? Answer: A Pap-nap is an abbreviated sleep study typically used to help patient adjust to a CPAP and is performed for less than 6-hours during the day. The American Academy of Sleep Medicine recommends providers use CPT code 95807-52. A typical sleep study…


Lip Repair

February 16, 2017 Question: What is the difference between 40761 and 40527? I’m confused. Answer: Here are the code descriptions with the major differences bolded. 40761: Plastic repair of cleft lip/nasal deformity; with cross lip pedicle flap (Abbe-Estlander type), including sectioning and inserting of pedicle. 40527: Excision of lip; full thickness, reconstruction with cross lip…


Septal Cartilage Graft and Septoplasty

February 2, 2017 Question: My doctor did a septoplasty, CPT 30520, removed cartilage and fashioned it for a graft that he used in the surgical repair of vestibular stenosis, CPT 30465. Can we also code 20912 for the fashioning of the graft or just 30520 and 30465? I couldn’t find any CCI edits preventing this….


Excisional Biopsy

January 19, 2017 Question: My doctor’s documentation for a biopsy indicates he performed an “excisional biopsy of the skin”. Is this correct? Answer: No, CPT does not have a code for excisional biopsy. It is either a biopsy (11100 or 11101) or a benign or malignant excision code. (114xx, 116xx). It is important to use…


Myringotomy and Tube – Same Ear

January 5, 2017 Question: Can we bill myringotomy 69421 and tube 69436 in the same ear? My doctor says no but I don’t see why not. Answer: We agree with your doctor. The myringotomy is required in order to place the tube; therefore, 69421 is considered an integral component of 69436 and should not be…


Pharyngoplasty With Free Flap Reconstruction

December 15, 2016 Question: I’m doing the repair of the oral cavity defect with a free flap reconstruction after the head and neck surgeon has resected the cancer. Can I code both 42950 and the free flap code such as 15758? Answer: The free flap codes include the harvest, inset, microvascular anastomosis, and closure of…


Endoscopic Septoplasty

October 27, 2016 Question: Is there a code for an endoscopic septoplasty? Answer: There is not a separate code for an endoscopic septoplasty nor is there an add-on code for the endoscope. You’ll use 30520, the usual septoplasty code. *This response is based on the best information available as of 10/27/16.


Removal of Mandibular Interdental Fixation

October 13, 2016 Question: We did a mandibular fracture repair on a patient (car accident) and placed the interdental fixation as part of the fracture repair. We saw the patient in the office, about 8 weeks postop, for a visit and everything was looking good so we removed the wires/fixation. Is the removal separately billable…


Reimbursement: Co-Surgery

September 29, 2016 Question: What is the reimbursement for co-surgery using modifier 62? Is it different for the primary and co-surgeon? Answer: For Medicare, co-surgery requires two different specialties performing separate parts of a single CPT code. For both surgeons, modifier 62 is appended to the appropriate CPT code(s). Medicare multiplies the allowable by 125%…


Diagnosis Code for Laryngopharyngeal Reflux

September 15, 2016 Question: I’m getting used to ICD-10-CM! Thanks so much for teaching me about it. I do have a question though. I can’t seem to find a diagnosis code for laryngopharyngeal reflux. What do you suggest? Answer: Actually, we’ve always suggested using K21.9, Gastro-esophageal reflux disease without esophagitis. Coincidentally, in a recent issue…


Signing NPP Notes

August 18, 2016 Question: Do I have to sign each of my NP’s notes that are reported incident to? Answer: The guidelines for reviewing and signing NPP documentation are set by each state in its scope of practice regulations. Each practice must research those requirements individually. But as an employer, you are responsible for the…


Reimbursement: Assistant Surgeon

August 4, 2016 Question: What is the reimbursement for an assistant surgeon using modifier 80? Is the payment different for the primary and the assistant? Answer: Assistant surgeon is described as one surgeon, of the same or a different specialty, providing assistance during a surgical procedure or CPT code. Modifier 80 (modifier 82 for an…


Medicare X Modifiers: Use or not Use?

July 21, 2016 Question: What’s new with the X modifiers established by Medicare? Should we be using them now? Answer: As of today, Medicare has yet to finalize a formal policy for the use of the -X{EPSU} modifiers as a replacement for modifier 59. The -X{EPSU} modifiers are shown below but have not yet been…


Source for a Consult

July 7, 2016 Question: What is an appropriate “source” for a consult? I asked at a recent non-KZA workshop and the instructors did not have an answer. Answer: The guidelines for a consultation (inpatient or outpatient) state that the service must be requested by a physician or “other appropriate source”. Guidelines are not clear regarding…


New vs. Established Patient

June 23, 2016 Question: If I see a new patient and during that visit I identify the need for surgery the same day, should I append a Modifier 57 to the E/M service? Answer: Yes, if you determine during the evaluation that the patient needs a major procedure (90 day postop global period) the same…


Bilateral Procedures

June 9, 2016 Question: Our current billing service is using the 50 modifier when we indicate that it is a bilateral procedure for tubes and sinus procedures. However, they are doubling the amount charged when billing for tubes (69436-50) but not for the sinuses. Can you advise me of the proper way for this to…


Approach to Pituitary Tumor

May 26, 2016 Question: I am with Otolaryngology and one of our Physicians has done a case with a Neurosurgeon. I need some advice regarding coding. They did a transsphenoidal pituitary tumor together where our physician opened and assisted the neurosurgeon. The neurosurgeon did 61548 and our physician said he did 30520, 31287-50, 31240-LT, and…


Follow-up Cerumen Impact E/M Visit

May 12, 2016 Question: A new patient only came in for an ear cleaning and I only billed for an ear cleaning (even though I do open a new chart for this patient) because there wasn’t really another diagnosis to support an E/M code. When the same patient comes back for a visit for sinusitis,…


Tympanostomy Tube with Intratympanic Injection

April 28, 2016 Question: I did an intratympanic steroid injection and coded 69801 and 69433. Medicare paid 69801. Should I appeal the denial of 69433? Answer: No! CPT 69801 says Labyrinthotomy, with perfusion of vestibuloactive drug(s); transcanal. The CPT guidelines say: Do not report 69801 in conjunction with 69420, 69421, 69433, 69436 when performed on…


Placement of Doyle Splints

April 14, 2016 Question: My doctor documents placement of Doyle splints in the nose which are sutured to the anterior septum after a septoplasty. Can I bill 31299 for this? Answer: No, placement of intranasal splints, dressings and packing is part of the wound closure and not separately reported. *This response is based on the…


New or Existing Patient Coding

March 31, 2016 Question: If I see a new patient (9920x) for an ear problem, then they come back to see me for chronic sinusitis a year later, can I bill as a new patient visit (9920x) the second time or is it an established patient (9921x)? Answer: No, this would be an established patient…


Use of Tissue Adhesive for Laceration Repair

March 17, 2016 Question: Does use of a tissue adhesive “count” as a layer for the laceration repair codes? Answer: Actually, yes it does! The CPT guidelines state “Use the codes in this section to designate wound closure utilizing sutures, staples, or tissue adhesives (e.g., 2-cyanoacrylate), either singly or in combination with each other, or…


Modifier 25 and Audiograms

March 3, 2016 Question: When I bill an E/M code such as, a new patient or established patient visit, do I need to append modifier 25 when I also bill for an audiogram? Answer: No, not for Medicare claims. Modifier 25 is appended to the E/M code to show your service is above and beyond…


Cerumen Removal vs. E/M Code

February 18, 2016 Question: Someone told me to bill an E/M code like 99212 or 99202, instead of 69210 when removing impacted cerumen with instrumentation. What do you think? Answer: Absolutely not! The ICD-10-CM code for cerumen impaction (H61.20 – H62.23) supports reporting a CPT code for the removal (69210). Also, Medicare’s payment for 69210…


Excision of Skin Lesion

February 2, 2016 Question: I heard you say at a course (you were great, by the way, I learned a lot from you!) that we should wait for a pathology report before billing for excision of skin lesions.  Please explain why.  This may be why I’m not getting paid. Also, when is your next ENT…


Repair of Nasal Vestibular Stenosis

January 14, 2016 Question: I am trying to come up with the right CPT codes for a repair of nasal vestibular stenosis so we can get it pre-certified. Can you help? Answer: Yes, you are wise to determine the correct codes for pre-certification, otherwise the surgery might not be paid if you billed different codes. …


Cerumen Removal

December 17, 2015 Question: I was in attendance at the “top ten coding issues” talk that you gave in Dallas at the AAOHNS annual meeting.  Great talk, Kim! We spoke regarding CPT 69210 after the session. I just want to confirm that use of magnification is not necessary for this code. My associates insist that…


Endoscopic Skull Base Surgery

12/03/15 Question: We are thinking about starting an endoscopic skull base surgery program and doing skull base procedures via an expanded endonasal/endoscopic approach. I’ve looked in the CPT book for codes and it looks like CPT 61580-61619 are just what I’m looking for. Is this correct? Answer: That’s great that you’re starting a new program!…


Cerumen Removal….Again

November 5, 2015 Question:   I just wanted to verify the guidelines for billing cerumen removal (69210). Before, it needed to state that the cerumen was “impacted” to be able to bill CPT 69210. I was just told that guideline has changed and that anything that goes in the body (I’m thinking like a curette to…


ICD-10-CM for Otitis Media

September 24, 2015 Question:   I am hoping that ICD-10-CM has codes for recurrent acute otitis media since this is one of the most common reasons why we put in tympanostomy tubes. Did this happen? Answer: Yes – someone must have heard you! Many of the otitis media codes now specify acute, acute recurrent, and chronic….


ICD-10-CM for Bilateral Cerumen Impactions

September 10, 2015 Question:   I noticed that the ICD-10 codes for many ear conditions are specific for right, left and bilateral. But what if I am billing for a bilateral procedure, such as tympanostomy tubes? Should I use the right and left codes, or should I use the bilateral code? Answer: Good question! If a…


Holding Claims for Path Reports

August 13, 2015 Question:   Do you advise that we hold our claims for excision of skin lesion procedures until after the pathology report is received? That seems to delay our charges and I want to get them billed quickly! Answer: Yes, you need to hold the claim for the excision of skin lesion codes (114xx…


Lipoma Removal

July 30, 2015 Question:   I removed a huge lipoma from a patient and it seems like the benign skin lesion removal codes just don’t describe what I’m doing. Is there another code I can use? Answer: Yes! The “soft tissue tumor” codes were introduced into CPT in 2010 and better describe the procedure you are…


Diagnosis Code

July 16, 2015 Question:   I do a lot of reconstruction procedures after the Mohs surgeon has removed the skin cancer. I am not removing cancer so it doesn’t seem right to use a cancer diagnosis code. But what diagnosis code should I use? Answer: We recommend using an “open wound” diagnosis code since the purpose…


Nasal Sinal Displacement Therapy

July 2, 2015 Question:   After bilateral endoscopic sinus surgery is completed, my doctor documents “the patient then underwent bilateral nasal sinal displacement therapy and all bloody secretions and mucoid secretions were clear.” He wants to bill 30210-50 (Displacement therapy (Proetz type)) in addition to the endoscopic sinus surgery codes. Is that acceptable? Answer: No. Irrigation…


Harvest of Abdominal Fat Graft

June 11, 2015 Question:   My doctor harvested abdominal fat that he then used in the nose to close the area when he did an endoscopic removal of a pituitary tumor (62165). I want to bill 15770 but my doctor thinks the correct code is 20926. What do you recommend? Answer: Your doctor is correct with…


Paramedian Forehead Flap After Mohs Surgery

May 21, 2015 Question:   I did a paramedian forehead flap after the Mohs surgeon removed the cancerous lesion from the nose. What is the CPT code for this procedure and do I need a modifier because I’m in the Mohs surgeon’s global period? Answer: The code is 15731 (Forehead flap with preservation of vascular pedicle…


Repair of Nasal Vestibular Stenosis

May 7, 2015 Question:   I will sometimes do a septoplasty with the repair of nasal vestibular stenosis. Is it OK to bill both codes together? Answer: Yes, it sure is assuming the documentation supports both separate services. CPT 30520 (septoplasty) is not included in the code for nasal vestibular stenosis repair (30465, Repair of nasal…


CPT 92547: Use of Electrodes

April 9, 2015 Question:   What happened? I used to bill 92547 – use of electrodes during electronystagmography – with 5 units and now Medicare will pay only one unit. Answer: Yes, this changed as of 1/1/15 as Medicare’s MUE (medically unlikely edits) now allow payment for only 1 unit.


Changes to CPT Esophagoscopy Definition in 2015

March 12, 2015 Question:   I did a direct laryngoscopy, bronchoscopy and esophagoscopy for tumor staging. Are all three codes billable? Answer: Yes, but make sure that you performed what CPT now says is included in the esophagoscopy. Effective 1/1/15, CPT added this guideline: “Esophagoscopy includes examination from the cricopharyngeus muscle (upper esophageal sphincter) to and…


Intraoperative Monitoring

February 26, 2015 Question:   I would like to know the codes I can bill for neural monitoring during a thyroidectomy, mastoidectomy, and parotidectomy cases. Answer: Intraoperative neural monitoring is included in the global surgical package for the surgical procedure code(s) billed by the surgeon; therefore, the surgeon would not bill for this service. Placing the…


Measuring Square Centimeters

February 5, 2015 Question:   I’m confused about how to determine the square centimeters for using the Adjacent Tissue Transfer codes (14000-14302). Can you explain it in terms that I will understand? I’m not a doctor. Answer: I will certainly try! The adjacent tissue transfer codes are used when there is a primary defect that results…


Ear Canal Debridement…Again

January 22, 2015 Question:   What CPT code would I use for a debridement of purulent debris from the ear canal, with or without placement of a wick in, such as when the patient has Swimmer’s ear? One of my colleagues told me he bills cerumen removal (69210) because there is always a little bit of…


Weekend Rounds (Part 2)

January 8, 2015 Question:   Thanks for answering my question last time – I get it now that I would not charge for rounding on post-op patients of my call partners. What about non-surgical patients? Can I bill for making rounds? Answer: Yes, absolutely! As I said, you should treat the patient as if it were…


Weekend Rounds

December 23, 2014 Question:   I have just a quick question regarding weekend rounding. I share weekend call with another practice that I am not affiliated with. Sometimes, when rounding, I check on 5-10 of their patients, some of which are their post-ops and some have not had surgery. Since I am not part of their…


UPPP & Tonsillectomy

December 11, 2014 Question:   Can you tell me if in fact the tonsillectomy code is bundled into the UPPP code? We are having an argument about that in our office and would appreciate it if you’d weigh in. Answer: That’s a very good question. From a CPT coding standpoint, the tonsillectomy code may be separately…


ICD-10 “X” Placeholder

October 16, 2014 Question:   I recently listened to a webinar on ICD-10. They discussed the x placeholder, but I still don’t understand exactly when to use it. Can you help explain? Answer: Absolutely we can help! The “X” placeholder has two functions in ICD-10-CM. First, it is used with some codes as a placeholder for…


7th Character Extension in ICD-10

October 2, 2014 Question:   Our practice sees a fair number of patients with a diagnosis of “open wounds”. I was looking at these codes in ICD-10 and noticed a character needs to be added to say whether the encounter is initial or subsequent. Is the first visit with the doctor always A for initial and…


Different Procedures, Different Ears

September 18, 2014 Question:   One of our doctors did a tympanoplasty on the right ear and a paper patch on the left ear. These codes are bundled. Can I be paid for both procedures? If so, how do I code this? Answer: While these codes are bundled, you are right that you should be paid…


Drainage of a Postoperative Seroma

September 4, 2014 Question:   We had a patient come into the office for their postop check after a thyroidectomy and neck dissection. The doctor ended up having to drain a seroma. I sent the claim into Medicare with a 78 modifier, but it was denied as included. Did I use the wrong modifier? Answer: Payment…


Orders for Audiology Testing

August 21, 2014 Question:   Someone just told me that we need to have an order on the chart for audiology testing. Is this true? Answer: Yes, Medicare requires an order from a physician or non-physician practitioner (NPP), such as a Physician Assistant or Nurse Practitioner, to bill and be reimbursed for audiologic diagnostic testing services….


Billing for an Audiologist

August 7, 2014 Question:   Can we bill our audiologist’s services under the physician’s name and NPI? Answer: It depends on the payer. Medicare requires, and has since 2008, audiologists to be credentialed and bill under their own NPI (National Provider Identifier) for any services personally performed. Thus, any services personally performed by an audiologist cannot…


Adjacent Tissue Transfers

July 24, 2014 Question:   If my doctor does more than one adjacent tissue transfer, do I add them together and bill one code or do I bill them separately? Answer: No, you do not add them together and bill one code. The adjacent tissue transfer (ATT) or rearrangement CPT codes 14000-14302 are reported per defect….


Tonsillectomy with UPPP

June 26, 2014 Question:   Is it OK to bill for tonsillectomy and a UPPP separately? Most of the payers deny this as a bundled service when the two codes are submitted together. Answer: Yes, per the AMA’s CPT coding guidelines and the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS), these are separate and distinct…


Nasal Septal Graft Bundling

June 12, 2014 Question:  My physician did a septoplasty and also harvested a graft from the septum for repair of nasal vestibular stenosis. I billed CPT 30465 (nasal vestibular stenosis repair), 30520 (septoplasty) and 20912 for the septal graft. Insurance denied the graft code as bundled. I tried to appeal this and was denied. Shouldn’t…


Sub-Specialty Otolaryngologists

May 29, 2014 Question:   I am new to credentialing at my clinic. We have 3 ENT doctors and a new physician joining the practice in the next few months. The new physician is a Pediatric Otolaryngologist. I am starting the initial paperwork, but can’t find a specialty code for Pediatric Otolaryngology. Should I credential him…


Removal Of Nasal Pack

May 15, 2014 Question: A patient came to the office after being seen in the emergency room with a nasal pack in place. I removed the nasal pack, but can’t figure out how to bill for taking it out. The nasal control codes only seem to be for placement. Answer: There isn’t a code for…


Suture Removal

May 1, 2014 Question:   We had a patient come into our office to have their sutures removed from a facial laceration repaired by someone else. The patient was hurt while on vacation and couldn’t have the sutures removed while away. The problem is the patient is still in the global period from the repair performed…


Medication Refills

April 17, 2014 Question:   The physician I work for will often send patients home with two different samples of medication to try to see which works best for them. When the patient calls back to tell the physician which medication has worked, the physician writes the prescription and sends it into the pharmacy. He has…


Cerumen Removal 2014

April 3, 2014 Question:   I noticed that I am getting denials from Medicare when I use modifier 50, bilateral procedure on 69210. I thought we were allowed to bill with modifier 50 as of January 1, 2014. What should I do? Answer: This has been an ongoing issue since the code 69210 was revised effective…


Excision of a Skin Lesion

March 6, 2014 Question:   When coding for excision of a skin lesion (114xx, 116xx), do I use the size on the pathology report to determine the correct CPT code? Answer: The most accurate measurement, according to CPT, is when the lesion has not yet been excised and is still on the patient. The specimen reduces…


Postop Mastoid Debridement

February 20, 2014 Question:   My doctor did a mastoidectomy on a patient. Can we bill for the mastoid debridement using 69220 when the patient comes back to the office for a postop debridement? Answer: The mastoidectomy codes (e.g., 69641-69646) have a 90-day postoperative global period and include all postoperative care related to the mastoidectomy procedure….


Debridement of Ear Canal

February 6, 2014 Question:   We billed 11000 (Debridement of extensive eczematous or infected skin; up to 10% of body surface) for debridement of an ear canal with a diagnosis code of otitis externa (380.23). The payor denied 11000 and say there was no “medical necessity” documented. I don’t get it. Please help. Answer: The denial…


Stand-by Services

January 23, 2014 Question:   What is the right code and way to document a stand by tracheostomy? Here’s a clinical scenario… 70 y/o woman comes in to the ER with tongue swelling, she has respiratory distress needs intubation. I get called in to stand by while the anesthesiologist performs an intubation. I will need to…


Intraoperative Monitoring

Question:   OK, so I now realize that I should not be billing for intraoperative monitoring based on the CPT changes for 2013. The consultants at KZA have been saying this for years and I’m now on board with you. My question is: Can I at least bill the codes 95867 or 95868 for the surgeon…


Intraoperative Monitoring

Question:   When performing a thyroidectomy or parathyroidectomy, and a physician’s assistant is assisting, can the PA bill for the nerve monitoring codes, 95867, 95868, +95940? Answer: No, neither the surgeon or an assistant surgeon or even a co-surgeon may bill for intraoperative nerve monitoring.



Question:   Our audiologist is doing this new test called VEMP? The equipment vendor gave me a big long list of codes to bill for this test including the ENG, EMG and other diagnostic testing codes. It just doesn’t seem right. What is your advice? Answer: We agree that billing ENG and EMG codes isn’t accurate…


Nasal Endoscopy

Question:   I did a nasal endoscopy (31231) and adenoidectomy (42830) on a young child. The insurance company denied the nasal endoscopy but paid on the adenoidectomy. I wouldn’t think these two codes are bundled. What do you think? Answer: To answer your question, we requested the operative report from you to see what the documentation…


Skin Lesion Removal and Closure

Question:   I have a question on lesion removal and closure coding. If two lesions the same size, same diagnosis (e.g., malignant) and same area (e.g., neck) are removed, is the code used twice or are the sizes added together for one code? I have the same question for a repair- same site (per code description),…


ER Discharge

Question:   Our surgeon was called to the Emergency Room to see a patient in consultation. The patient was discharged from the Emergency Room. Can you tell us how to report this? Answer: The correct category of CPT code will be dependent on payor rules. According to the 2013 AMA CPT rules, the service is a…


Calculating Size for Codes

Question:   I’m new to coding. My doctor and I have a disagreement on how to calculate the size for the adjacent tissue transfer codes (140xxx). The doctor says there was a 16.5 cm by 7 cm wound that he did an adjacent tissue transfer to close. I think I should use a code for a…


Inferior Turbinate Submucous Resection and Outfracture

Question:   I did an inferior turbinate submucous resection removing subcutaneous tissue and bone followed by out-fracturing with the Boise elevator. Can I bill 30140 for the submucous resection and 30930 for the out-fracture? Answer: Actually, CPT specifically says “Do not report 30801, 30802, 30930 in conjunction with 30130 or 30140.” Therefore, it would not be…


Intraoperative Laryngeal Nerve Monitoring

Question:   Can I bill for intraoperative laryngeal nerve monitoring when I am doing procedures such as a parathyroidectomy or thyroidectomy? Answer: No, intraoperative monitoring is not separately billable for the surgeon. Intraoperative monitoring has always been included in the global surgical package for surgeon and CPT now actually documents this in the CPT 2013 manual.


Endoscopic Concha Bullosa Resection with Other Sinus Procedures

Question:   I did endoscopic sinus surgery (maxillary antrostomies and anterior ethmoidectomies) as well as endoscopic bilateral resection of concha bullosa. I told my biller to submit the following codes for me: 31254-50, 31256-50, 31240-50. My biller says the concha bullosa resection code is “bundled” into the other codes and she won’t submit the codes. I…


Maxillary Sinus Lavage (31000)

Question:   My doctors want to bill 31000 for a maxillary sinus lavage every time they do an endoscopic procedure on the maxillary sinus such as 31256 (endoscopic maxillary antrostomy), 31267 (endoscopic maxillary antrostomy with tissue removal from within the sinus) and 31295 (endoscopic balloon dilation of the maxillary sinus). The lavage is bundled with 31256…


Thyroidectomy with Central Neck Dissection

Question:   How do I code a thyroidectomy for malignancy with bilateral central neck dissections? I see 60252 for Thyroidectomy, total or subtotal for malignancy; with limited neck dissection but not bilateral central neck dissections. Answer: Actually the central neck is not considered to be a structure that has laterality to it – central is middle….


Direct Laryngoscopy with Multiple Biopsies

Question:   I did 31535 Laryngoscopy, direct, operative, with biopsy but took multiple biopsies through the laryngoscope of the hypopharynx and base of tongue looking for an unknown primary malignancy. Can I report 31535 more than once to account for the multiple biopsies? Can I bill 42802 (Biopsy; hypopharynx) with the direct laryngoscopy? Lastly, what if…


Modifier 25

Question:   Do we have to append modifier 25 to the E&M code if only an audiogram were also performed at that same visit? Or does modifier 25 not apply since the audiogram is a diagnostic test? What about when we do an in-office CT on the same day as an office visit – should we…


Nasal Fracture Repair vs. Rhinoplasty

Question:   I did an open treatment of a nasal fracture repair and septoplasty on a patient who was in a bar fight two years ago on spring break and had his nose broken. He now has nasal airway obstruction and deviated nasal septum as well as displaced nasal bones. I billed 21335 (Open treatment of…


Endoscopic Zenker’s Diverticulectomy

Question:   I can’t find a code for this procedure. I found 43130 (Diverticulectomy of hypopharynx or esophagus, with or without myotomy; cervical approach) but it doesn’t say endoscopic so I’m not sure if I should use it. Answer: You are right to be cautious! CPT 43130 requires a skin incision so it should not be…


Botox of the Parotid Gland

Question:   What is the code for injection of Botox the parotid for hyperhidrosis or to control excessive oral secretions? Answer: The code you are looking for is 64611 (Chemodenervation of parotid and submandibular salivary glands, bilateral). The code assumes you are doing at least four injections: right parotid, right submandibular, left parotid and left submandibular)….


Myringoplasty and Cartilage Graft

Question:   I have a question regarding the correct coding of a myringoplasty with cartilage graft patch. Is the correct coding for this case: 21235-RT and 69620-51? Answer: CPT 69620 (Myringoplasty (surgery confined to drumhead and donor area)) specifically states that the code includes the “donor area.” Therefore it is not appropriate to report a separate…


Ear Canal Debridement

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…


Allergy Injection Supervision Requirements

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…


Removal of Nasal Pack

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,…


Allergy Injection

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…


Myringoplasty and Fat Graft

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…


New or Established Patient

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…


Le Fort Fractures

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…


Removal of Tube in Office

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…


Tonsils / UPPP Revisited

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…


30930 and 30140

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…


Removal of Tube in Office

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…


Endoscopic Zenker’s Diverticulum

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…


E&M Visit with Allergy Injection

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…


Ear Exam Under Anesthesia

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…


Wound Cultures

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…


Written Physician Order for Audiologic Evaluations?

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…


CPT and Diagnosis Codes for a Skin Lesion

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…


Coding Multiple Z-Plasties

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…


Different Procedures / Different Ears

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…


Medicare Supervision Requirements for Audiologists

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…


Intranasal Application of Medication

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….


Endoscopic Polypectomy

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…