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The Otolaryngology Coding Coach 2013 Archives

Intraoperative Monitoring

December 26, 2013


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 at the time of the surgical procedure? My doctor wants to get paid something for placing the needles.


No, placing the needles is part of the procedure set up and not separately reported. It is not accurate to call it an EMG (95867, 95868).

CPT 31541 – Can it Be Billed Bilaterally?

December 12, 2013


One of my physicians wants to code 31541 bilaterally; so far it has been denied each time. Can you tell me if this is allowed or am I wasting my time? Also I would like to attend one of AAOHNS/KZA seminars, are they for office staff as well as physicians?


Absolutely - office staff may attend the coding course such as the one your physician attended. It would be great if you could go as well. Practices find it extremely helpful when the physician and billing staff attend together.

It isn’t surprising that payors are denying payment for 31541-50 (modifier 50 for bilateral procedure). CPT 31541 states: Laryngoscopy, direct, operative, with excision of tumor and/or stripping of vocal cords or epiglottis; with operating microscope or telescope. Because the code says vocal cords, meaning both vocal cords, 31541 should not be billed with modifier 50.

Intraoperative Monitoring

November 26, 2013


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?


No, neither the surgeon or an assistant surgeon or even a co-surgeon may bill for intraoperative nerve monitoring.


November 14, 2013


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?


We agree that billing ENG and EMG codes isn’t accurate for the VEMP test. Actually, the March 2011 CPT Assistant that is published by the American Medical Association states that there is no code for vestibular evoked myogenic potential (VEMP) testing. Therefore, an unlisted code (92700) is used to report this service.

Nasal Endoscopy

October 31, 2013


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?


To answer your question, we requested the operative report from you to see what the documentation says. Your note lists “adenoid hypertrophy” as a pre- and post-operative diagnosis. The body of the operative report states: “The nasal endoscope was placed down into the posterior nasopharynx and there was a large adenoid pad. There was clear mucoid fluid around the bilateral nasal cavities.” Then the operative report describes the adenoidectomy procedure.

It appears that the nasal endoscopy was a diagnostic procedure to confirm the pre-operative diagnosis of adenoid hypertrophy. The diagnostic nasal endoscopy procedure was followed by a more definitive surgical procedure (adenoidectomy). Therefore, only the definitive procedure – the adenoidectomy - is reported. It would not be appropriate to bill for the nasal endoscopy (31231) in this scenario.

PQRS Reporting Requirement In 2013

October 17, 2013


I have not participated in Medicare’s Physician Quality Reporting System yet. I just heard that my Medicare payments will be reduced if I don’t participate. What do you suggest I do?


You are correct – Medicare will reduce your 2015 payments if you do not participate in PQRS in 2013. The minimum participation is to submit one valid quality measure code (QMC) at least once in 2013. You’ll want to submit, to Medicare Part B patient (do not include Advantage plan patients) in 2013. We suggest you submit on several patients, not just one, to make sure Medicare has recorded this information from you.

Want more information? Please click here to see KZA consultant Cheyenne Brinson’s webinar.

A Letter From a Private Payor About My E & M Coding. Should I Be Concerned?

October 3, 2013


I received a letter from a private payor saying I report a higher percentage of 99204, 99205, 99244 and 99245 services than my peers. The letter advised me to review the E & M requirements for these codes. Should I be concerned?


Yes you should! This is essentially a warning letter that your payor is trending your E&M services and has identified you as an outlier with these levels of service in comparison to your peers. You may choose to contact your healthcare attorney to determine next steps. This may include an internal or external review of E&M services that were reported with these E&M codes or perhaps some one-on-one E&M Coding and Documentation education. You should also run a CPT frequency report (may be called a productivity report in your system) and benchmark yourself and your group, if appropriate, to state and national benchmark data. This data is available from the Medicare website or KZA can assist you with our E & M Analyzer.

The Analyzer, provides you with a comprehensive assessment of your E & M coding patterns as compared to your peers and where you might be at risk. Click here to find more information about the E&M Analyzer. Now is the time to act as your payor has already identified they are paying attention.

Skin Lesion Removal and Closure

September 5, 2013


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), same type of closure (e.g., intermediate) – do we add the lengths together or use the same code twice?


We cover these exact questions in the AAOHNS/KZA coding courses. Report one CPT code for each lesion removed. Use modifier 59 on the second and subsequent same CPT codes. For example, removal of two malignant lesions of the neck each 1.2 cm in diameter are reported using 11642 and 11642-59. Be careful because some payors (including Cahaba Medicare) require the use of modifier 76 rather than 59 in the situation where more than one of the same CPT codes is billed on the same date of service.

For the repair codes, you will sum the repairs for similar types of repairs (e.g., intermediate, complex) in similar anatomic locations (per CPT code). Bottom line is lesion removal codes are never added together but the wound repair codes may be summed.

ER Discharge

August 22, 2013


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?


The correct category of CPT code will be dependent on payor rules. According to the 2013 AMA CPT rules, the service is a consultation and the 99241-99245 codes are reported. Report the consultation code for all payors still recognizing this category of codes.

Medicare no longer reimburses consultation service, thus a CPT code from the Emergency Department (ED) Codes (99281-99825) will be reported when the patient is seen in consultation in the Emergency Room and discharged to home.

Endoscopic Sinus Debridements: Reportable or Not?

August 8, 2013


Is appropriate to bill 31237-79 at the 1 week post op for our sinus surgery patients? I can’t help but feel that service would be included in the septoplasty or the turbinate surgery performed at the same session. The physician and office manager it should be billed when performed during the global period, but I just can’t figure out why. Can you help me understand if the debridement services are or are not separately reportable during the global period?


Thanks for your inquiry! The coding of sinus debridements and how to report is a frequently asked question. The endoscopic sinus surgery codes 31256, 31267, 31254, 31255, 31287, 31288, 31276 do not have a global period. Because there is no global period the debridement service (31237) is separately reportable after the surgery when medically necessary and supported by documentation. You are correct to question the use of the modifier 79 (unrelated surgical procedure) as the correct way to report this service. The septoplasty and turbinate surgery (30130, 30140) have 90 day global periods, thus the use of modifier 79 is required to indicate the debridement, performed at different anatomic locations is separately reportable. Remember, CPT code 31237 is a unilateral procedure and may be reported with a modifier 50.

Calculating Size for Codes

July 25, 2013


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 23.5 square centimeter code because 16.5 plus 7 equals 23.5. My physician said we are to multiply the numbers so it would be 115.5 square centimeters. Who is right?


Your physician is right. Area is measured in square centimeters and obtained by multiplying the length times the width of the wound. You will use CPT 14301 for the first 60 square centimeters (sq cm), add-on code 14302 for the next 30 sq cm and +14302-59 for the remaining 25.5 sq cm. Alternatively, you may report 14301 and 14302 x 2 units if you know that the payor will recognize more than 1 in the units box and reimburse the appropriate amount.

Intraoperative Angiography During Microvascular Flap Surgery

July 11, 2013


I am doing this new thing during my microvascular free flap procedures where I do intraoperative fluorescent angiography (Spy) to evaluate tissue perfusion prior to closing the wound. I’m told I can bill CPT 15860 intravenous injection of agent (e.g., fluorescein) for this in addition to the microvascular free flap code. I’ve tried billing it the last couple of times but I can’t get the insurance company to pay for it. Please help.


Anything you need to do to test the vascular flow in flap such as using a Doppler, tissue oximetry, or injecting fluorescein is included in the code for the primary procedure. Checking tissue perfusion and vascular flow is an inherent part of doing a microvascular free flap and not a separately billable procedure.

Inferior Turbinate Submucous Resection and Outfracture

June 27, 2013


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?


Actually, CPT specifically says “Do not report 30801, 30802, 30930 in conjunction with 30130 or 30140.” Therefore, it would not be appropriate to report 30140 and 30930 on the same turbinate. CPT 30930 may be reported when you do an out-fracture alone.

Intraoperative Laryngeal Nerve Monitoring

June 13, 2013


Can I bill for intraoperative laryngeal nerve monitoring when I am doing procedures such as a parathyroidectomy or thyroidectomy?


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

May 30, 2013


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 say it is a separate procedure and should be billed. What do you think?


We agree with you. The work of an endoscopic concha bullosa resection (31240) is not included in the endoscopic maxillary sinus or ethmoid sinus surgery codes (31256, 31267, 31254, 31255) and may be separately reported. There is no CCI edit that bundles 31240 into the other codes. However, some payors may have their own software that does bundle 31240 so you may need to append modifier 59 to 31240 to show this procedure was distinctly separate from other procedures performed at the same operative session.

How Do I Calculate The Size of An Adjacent Tissue Transfer Code

May 16, 2013


I am inquiring how to calculate the size of a wound to determine which adjacent tissue transfer code should be reported. The surgeon excised a dematofibrosarcoma protuberans of the chest that resulted in a primary and secondary defect documented as a 16.5 x 7. The secondary defect was closed primarily. My surgeon says the size of the defect is 115.5 sq cm and I am saying the wound size is 23.5 sq cm. Who is right?


Your surgeon is right. To report adjacent tissue transfers, the wound size is based on square centimeters (sq cm). To determine the total size of the wound defect, the defect size is determined by first multiplying the length times the width of the primary and secondary defects and adding both of them to determine the total defect size when the secondary defect is closed primarily as noted. Report CPT 14301 for the first 60 square centimeters (sq cm), add-on code 14302 for the next 30 sq cm and +14302-59 for the remaining 25.5 sq cm. Alternatively, you may report 14301 and 14302 x 2 units if you know that the payor will recognize more than 1 in the units box and reimburse the appropriate amount. Please note, some payors may not require the modifier 59 on the second add-on code.

Maxillary Sinus Lavage (31000)

May 2, 2013


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 and 31267 when I look at Medicare’s Correct Coding Initiative edits but I can bypass the edit using modifier 59 (distinct procedural service). Is it appropriate for us to append modifier 59 to 31000 in these instances? CPT 31000 is not bundled with the balloon dilation code, 31295, so it must be ok to bill both codes.


It is not appropriate to append modifier 59 to 31000 just to get the procedure paid. You must meet the criteria for use of modifier 59 in order to use the modifier appropriately and bypass the CCI edits. In these three examples, it is not accurate to separately report 31000 with or without a 59 modifier. The lavage is a lower-valued procedure performed at the same operative session on the same structure (maxillary sinus) and, therefore, would be included in the primary procedure codes of 31256, 31267 or 31295. Do not separately report 31000 for maxillary sinus lavage.

Thyroidectomy with Central Neck Dissection

April 18, 2013


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.


Actually the central neck is not considered to be a structure that has laterality to it – central is middle. So if you are doing both side of the middle, then it is still a central neck dissection. CPT 60252 considers a central neck dissection to be included in 60252 and the code includes removing all the nodes around the thyroid; therefore, modifier 50 (bilateral procedure) does not apply.

Direct Laryngoscopy with Multiple Biopsies

April 4, 2013


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 I did a separate nasopharyngeal biopsy at the same time also looking for an unknown primary malignancy – can I bill separately for the nasopharyngeal biopsy?


CPT 31535 includes any number of biopsies obtained through the same surgical exposure as the direct laryngoscopy so it would not be appropriate to also report biopsies from the hypopharynx, vocal cords, arytenoids or the larynx areas. Any biopsies taken via the scope are included in 31536 not 42802 which does not define a biopsy via a laryngoscope. If a biopsy is not taken via the scope, then it may be separately reported using the appropriate biopsy code. Be sure to make this very clear in your operative note. You may separately report a code for the nasopharyngeal biopsy since that procedure is performed through a separate surgical exposure, the nose.

Modifier 25

March 21, 2013


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 append modifier 25 modifier to the E&M code or is it not required because the CT is a diagnostic test?


Good questions! The CPT descriptor for modifier 25 is: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service. CPT states: “It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient's condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed.” Recall, however, that there is no pre- or postoperative care associated with diagnostic testing such as audiograms or CT scans.

As you know, since 2008 Medicare has required audiologists to bill directly using the audiologist’s NPI as the billing provider. Therefore, it is not likely that you will have an E&M code and an audiogram on the same claim form to Medicare. So your question about appending modifier 25 to the E&M code is not applicable when the payor is Medicare.

Therefore, modifier 25 on the E&M code is not necessary when also reporting a diagnostic testing code such as an audiogram or CT scan. However, you might find that some payors require the use of modifier 25 but it is not a CPT coding requirement.

Nasal Fracture Repair vs. Rhinoplasty

March 7, 2013


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 nasal fracture; with concomitant open treatment of fractured septum) but the insurance company denied it. Did I do something wrong or should I appeal it by sending in pictures?


The nasal fracture treatment codes (e.g., 21310-21337) are to be used when you are treating an acute fracture, not an old or healed fracture. The rhinoplasty codes (e.g., 30420) are more appropriate when you are treating a healed fracture. You can try to appeal the denial but we suspect the insurance company will not pay for the procedure because they consider it to be “cosmetic.”

Endoscopic Zenker’s Diverticulectomy

February 21, 2013


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.


You are right to be cautious! CPT 43130 requires a skin incision so it should not be used for an endoscopic, or transoral, procedure. You should use an unlisted code, 43499 (Unlisted procedure, esophagus) for an endoscopic resection of a Zenker’s diverticulum.

Botox of the Parotid Gland

February 7, 2013


What is the code for injection of Botox the parotid for hyperhidrosis or to control excessive oral secretions?


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). Report 64611-52 (reduced services modifier) if you do less than four injections.

MSL with Lysis of Stenosis and Steroid Injection

January 24, 2013


I am going to do a procedure on a patient with tracheolaryngeal stenosis – a microlaryngoscopy with lysis of the stenosis using a laser and excision of granulation tissue followed by a steroid injection. I gave my surgery scheduler two CPT codes to precertify: 31541 and 31571. She is telling me that I can’t bill these two codes together. Can you please help?


Sure – be happy to. Let’s look at the code descriptions:

31541 Laryngoscopy, direct, operative, with excision of tumor and/or stripping of vocal cords or epiglottis; with operating microscope or telescope
31571 Laryngoscopy, direct, with injection into vocal cord(s), therapeutic; with operating microscope or telescope

First, 31541 does not describe lysis of stenosis and/or excision of granulation tissue rather it describes excision of a tumor and/or stripping of vocal cords. Unfortunately, there is no CPT code for microsuspension laryngoscopy (MSL) with lysis of tracheolaryngeal stenosis. Therefore, you’ll have to use an unlisted code, 31599 (Unlisted procedure, larynx) for this procedure. You can use 31541 as your comparison code if you think the procedures are similar.

Then, yes, you may also report 31571 for the MSL with steroid injection assuming you clearly document the separate medical necessity for the procedure in the operative report (e.g., to prevent recurrence of granulation tissue).

Myringoplasty and Cartilage Graft

January 10, 2013


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?


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 code for the graft harvest (e.g., 21235). In your scenario, you would report only 69620.

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