ENT Coding: Does Your Nose Know When You Are Coding It Correctly? Presented to: AAPC Annual Meeting Orlando, Florida April 16, 2013 Presented by: Kim Pollock, RN, MBA, CPC www.karenzupko.com Kim Pollock, RN, MBA, CPC Consultant and Speaker For over thirteen years, Kim Pollock has helped large group practices, as well as academic and solo practices, improve collections and efficiency. She is expert at auditing coding and documentation for all subspecialties of otolaryngology. She knows how to apply reimbursement principles to ensure otolaryngologists are paid accurately. She has over thirty years of healthcare experience working for and with otolaryngologists. Ms. Pollock understands the complexity of coding and reimbursement issues specific to otolaryngologists вЂ“ both from a clinical perspective and from a payor side. She is an expert in analyzing chart documentation and in reengineering practices to enhance the reimbursement process. She presents seminars and workshops for physicians and their staff on behalf of the American Academy of Otolaryngology-Head and Neck Surgery (AAOHNS), the American Association of Neurological Surgeons and the American Society of Plastic Surgeons. Ms. Pollock has also conducted programs for the American Academy of Professional Coders, the North American Spine Society, the American Neurotology Society and the Congress of Neurological Surgeons. Based on her previous years of administrative experience, Ms. Pollock has a unique understanding of the challenges facing academic medicine both clinically and organizationally. She has served as the Administrator of the Department of Otorhinolaryngology as well as Associate Vice President of Cancer Programs at the University of Texas Southwestern Medical Center in Dallas. Ms. Pollock was the representative for the AAO-HNS on the clinical practice expert paneltechnical group (CPEP-TEG) convened by CMS (formerly HCFA) to redetermine the practice expense portion of RBRVS. She served two terms on the Board of Directors for the Society of Otorhinolaryngology and Head-Neck Nurses, Inc. (SOHN) and has served on the Board for the Ear, Nose and Throat Nursing Foundation. Ms. Pollock is the recipient of the prestigious Presidential Citation Award from the SOHN as well as an Honor Award from the AAOHNS. Ms. Pollock holds a Masters of Business Administration Degree as well as a Bachelors of Science Degree in Nursing. She is also a certified coder through the AAPC. KZA Disclaimer This manual is not intended to provide legal advice to physicians and their staffs. If you have specific questions regarding the permissibility of your billing or other practices, we recommend that you consult legal counsel directly for assistance in evaluating any legal, regulatory or compliance issues regarding these matters. In the event that you choose to consult with outside legal counsel, KZA is available to work with such counsel, as appropriate, to meet your needs. CPT five digit codes, nomenclature and other data are copyright 2011 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Text and Format В© 2013 KZA, Inc. 2013 AAPC_ENT Coding (KP)_032113 2 CPT only В© 2012 American Medical Association. All Rights Reserved Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service CPT Says: 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. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier 57. For significant, separately identifiable non-E/M services, see modifier 59. Tips Used to indicate an E&M service is significant and separately identifiable on the same day as a minor procedure. Note, this modifier is not used to report an E&M service that resulted in decision to perform surgery. (Medicare defines this as a procedure with a global period of 0 or 10 days). Attach modifier 25 to the E&M service on same day as minor procedure. Allows significant, separately identifiable E&M service to be reimbursed on the same day as a minor procedure. Different diagnosis not required. DonвЂ™t forget: The global surgical package includes the E&M on the same day of a minor procedure unless there is вЂњsignificant, separately identifiableвЂќ reason and documentation for the service. ThatвЂ™s when you append modifier 25 to the E&M code. Example Example: New patient E&M for evaluation of hoarseness on same day as a flexible fiberoptic laryngoscopy (9920x-25 and 31575). Text and Format В© 2013 KZA, Inc. 2013 AAPC_ENT Coding (KP)_032113 3 CPT only В© 2012 American Medical Association. All Rights Reserved Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service The OIG says that modifier 25 is misused and overpayments have resulted. CMS carriers are auditing вЂ“ so are private payors. ALERT: Medicare Part B News (11/5/12) says otolaryngologists billed an E&M visit (99201-99215) appended with modifier 25 on 42.3% of 2011 Medicare claims. How often did you? REMEMBER: All procedure codes have an inherent E&M component. Ask yourself: What have I done that goes вЂњabove and beyondвЂќ a minimal E&M service that is included in that procedure code? And, does my documentation support that additional work and effort? Scenario Code(s) 1. New patient, 67 year old female, is seen for hoarseness. In additional to your usual exam, you also do a flexible fiberoptic laryngoscopy. You write an E&M note and a separate procedure note. 2. Established patient you saw two weeks ago returns for scheduled excision of skin lesions. You write an E&M note and a separate procedure note. 3. Established patient returns for follow-up of hoarseness after two weeks of voice rest. Her mirror exam is now within normal limits. However, she now complains of green drainage from her nose so you do a nasal endoscopy and diagnosis her with acute maxillary sinusitis and prescribe an antibiotic. You write an E&M note and a separate procedure note. 4. Established patient returns for follow-up of hoarseness after two weeks of voice rest. You do a flexible fiberoptic laryngoscopy on her and her exam is within normal limits. You ask her to return prn. You write an E&M note and a separate procedure note. 5. Established patient returns for follow-up of hoarseness after two weeks of voice rest. You do a flexible fiberoptic laryngoscopy on her and her exam is worse. You now prescribe speech therapy for her and ask her to return in 4 weeks. You write an E&M note and a separate procedure note. Text and Format В© 2013 KZA, Inc. 2013 AAPC_ENT Coding (KP)_032113 4 CPT only В© 2012 American Medical Association. All Rights Reserved Modifier 57: Decision for Surgery CPT Says: An evaluation and management service that resulted in the initial decision to perform the surgery may be identified by adding modifier 57 to the appropriate level of E/M service. Tips Used to reflect a surgery decision-making E&M service was performed on the day before or the day of a major procedure. (Medicare defines this as a procedure with a global period of 90 days.) Append modifier 57 to the E&M service same day or day before major, or unplanned, procedure. Allows payment for the E&M as well as the procedure. This typically is the decision making E&M for an emergent or unplanned major procedure. Different diagnosis not required. Do not use modifier 57 on an E&M code to report a routine pre-op visit or an H&P on the day of the elective procedure. Examples You are asked to see a non-Medicare patient in the emergency room at the request of Dr. ER to evaluate a deep neck abscess. You perform the consultation service (9924x-57) and take the patient to the operating room for I&D (21501). You admit a Medicare patient from your office to the hospital to treat a deep neck abscess with IV antibiotics and subsequently see the patient in the hospital on the same day to perform the admission H&P (9922x-57, AI). The abscess requires I&D the next day (21501). Text and Format В© 2013 KZA, Inc. 2013 AAPC_ENT Coding (KP)_032113 5 CPT only В© 2012 American Medical Association. All Rights Reserved Office Endoscopy Nasal Endoscopy 31231 Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure) Evaluation of the nasal passages Tip: The parenthetical statement вЂњ(separate procedure)вЂќ means this procedure may be billed when it is a completely separate procedure from others performed at the same operative session. Do not report a вЂњseparate procedureвЂќ when included in a more extensive CPT code (e.g., 31231 is included in all surgical endoscopic sinus surgery codes such as 31255). Diagnostic Sinus Endoscopy 31233 Nasal/sinus endoscopy, diagnostic with maxillary sinusoscopy (via inferior meatus or canine fossa puncture) 31235 Nasal/sinus endoscopy, diagnostic with sphenoid sinusoscopy (via puncture of sphenoidal face or cannulation of ostium) CPT 31233 and 31235 require a puncture or trocar cannulation prior to placing the scope into the sinus. Do not report 31233 or 31235 for diagnostic sinus endoscopy performed via an existing and patent opening into the maxillary or sphenoid sinus is incorrect. These procedures are typically performed in the operating room. Nasopharyngoscopy 92511 Nasopharyngoscopy with endoscope (separate procedure) Evaluation of the nose, nasopharynx and pharynx Flexible Fiberoptic Laryngoscopy (FFL) 31575 Laryngoscopy, flexible fiberoptic; diagnostic Evaluation of the nose, nasopharynx, pharynx and larynx Do not also report 31231 for nasal endoscopy performed at the same time Text and Format В© 2013 KZA, Inc. 2013 AAPC_ENT Coding (KP)_032113 6 CPT only В© 2012 American Medical Association. All Rights Reserved Office Endoscopy Transnasal Esophagoscopy 43200 Esophagoscopy, rigid or flexible; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) Requires evaluation of the esophagus down to the gastro-esophageal (GE) junction. Append modifier 52 (reduced services) if evaluation down to the gastroesophageal junction is not performed Tracheobronchoscopy 31615 Tracheobronchoscopy through established tracheostomy incision Use 31615 for full bronchoscopy via tracheostomy. Append modifier 52 (reduced services) if only tracheoscopy, without full bronchoscopy, was performed. See 31525 code series (direct laryngoscopy) for tracheoscopy (without full bronchial exam) when not performed via tracheostomy. FAQ Q: Can I bill for a mirror exam using the indirect laryngoscopy code (31505)? I do one on almost all my new patient visits. A: No, this is part of an ENT exam and not separately reported. Text and Format В© 2013 KZA, Inc. 2013 AAPC_ENT Coding (KP)_032113 7 CPT only В© 2012 American Medical Association. All Rights Reserved Office Endoscopy 31237 Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement (separate procedure) Example: Patient returns two days after endoscopic sinus surgery and septoplasty. The physician performs bilateral endoscopic sinus debridement. ICD-9-CM Code(s): 1. 473.2 Chronic Ethmoid Sinusitis 2. 473.0 Chronic Maxillary Sinusitis CPT Code/ Modifier(s) Description 31237-79 31237-50, 79 Endoscopy, unilateral Endoscopy, unilateral ICD-9-CM Code 1, 2 1, 2 8-NF Reported Expected RVUNF Paid 9.88 9.88 9.88 4.94 19.76 14.82 OR 31237-50, 79 Endoscopy, bilateral 1, 2 Debridement: The removal of foreign material, and devitalized, or infected tissue from or adjacent to a traumatic or infected lesion until surrounding healthy tissue is seen. Use CPT 31237 to report post-operative endoscopic debridements performed outside the 0-day global surgery period following FESS. Do not use CPT 31237 for non-endoscopic nasal sinus debridements. CPT Assistant, December 2011 Although two to three debridements in the first 30 days is typical for the majority of patients, once a week may be an appropriate frequency for postoperative debridement in select patients with difficult problems. However, the frequency and length of time for which debridement is medically necessary will vary from case to case and must be individualized, a conclusion, which multiple studies analyzing debridement outcomes have acknowledged. While their limited use will likely suffice in the majority of cases, there are situations in which a patient may require more frequent, very long-term debridements. Clinically, these include but are not limited to: o Persistent crusting within the surgical bed, o Adhesion formation noted upon examination, o More extensive surgery (e.g., complex frontal sinusotomies, neoplasm resections), o Underlying immunologic disorders, o Diffuse polyposis, o Revision FESS, mucociliary disorders, o Allergic fungal sinusitis, o And postoperative complications (e.g., visual loss, cerebrospinal fluid leak). Tip: Do not report an E&M code with 31237 unless there is also a significant, separately identifiable service provided (e.g., a different diagnosis such as acute otitis media). Text and Format В© 2013 KZA, Inc. 2013 AAPC_ENT Coding (KP)_032113 8 CPT only В© 2012 American Medical Association. All Rights Reserved Tonsillectomy/Adenoidectomy Tonsillectomy Alone 42825 < age 12 42826 в‰Ґ age 12 With Adenoidectomy 42820 < age 12 42821 в‰Ґ age 12 Adenoidectomy Primary (first one) 42830 < age 12 42831 в‰Ґ age 12 Secondary (subsequent) 42835 < age 12 42836 в‰Ґ age 12 Tips: All codes have a 90-day global period, per CMS Biopsy(ies) obtained of the nasopharyngeal tissue in conjunction with a T&A is not separately reported. May separately bill for the biopsy if only a tonsillectomy is performed. CMS says: Do not bill for treatment of complications in the global period unless there is a return to the OR (then append billed CPT code with modifier 78). Unplanned overnight stay on the day of procedure is not separately reported if reason is due to surgery (e.g., pain, dehydration). Unplanned re-admissions (e.g., dehydration) may be separately reported with modifier 24. What about post-op tonsillectomy bleeds? o In-office treatment вЂ“ Medicare says do not bill; check with other payors for policy o In ER вЂ“ Medicare says do not bill; check with other payors for policy o Return to the OR вЂ“ bill with modifier 78 п‚§ 42960 Control oropharyngeal hemorrhage, primary or secondary (e.g., post-tonsillectomy); simple п‚§ 42961 complicated, requiring hospitalization п‚§ 42962 with secondary surgical intervention (e.g., suture ligation of bleeders) п‚§ Primary = within 24 hrs after surgery, secondary = 24 hours to two weeks later п‚§ 42960 and 42961 involve clot evacuation, applying pressure with sponges, electrocautery, application of vasoconstrictor solutions such as tannic acid, silver nitrate and epinephrine. п‚§ 42962 involves surgical intervention (e.g., suture ligation of bleeding vessels) Refer to CPT 42970-42972 for postop adenoidectomy bleed control in the OR and append modifier 78. Text and Format В© 2013 KZA, Inc. 2013 AAPC_ENT Coding (KP)_032113 9 CPT only В© 2012 American Medical Association. All Rights Reserved Turbinate Procedures CPT Code Description Unilateral/ Bilateral 30801 Ablation, soft tissue of inferior turbinates, unilateral or bilateral, any method (e.g., electrocautery, radiofrequency ablation, or tissue volume reduction); superficial Unilateral or Bilateral (no modifier 50) 30802 Unilateral or Bilateral (no modifier 50) intramural (i.e., submucosal) 30930 Fracture nasal inferior turbinate(s), therapeutic Unilateral or Bilateral (no modifier 50) 30130 Excision inferior turbinate, partial or complete, any method Unilateral (modifier 50 acceptable) 30140 Submucous resection inferior turbinate, partial or complete, any method Unilateral (modifier 50 acceptable) Coding Tips: Do not report 30801 in conjunction with 30802 For 30140: The documentation should indicate the mucosa was entered/incised and preserved and tissue and/or bone was removed. A statement such as вЂњexcised the turbinate(s)вЂќ is not sufficient to accurately take into account the submucous resection of the inferior turbinate(s), and would not support 30140. Do not report 30140-52 for вЂњturbinate reductionвЂќ вЂ“ refer to 30801 or 30802. Do not report 30801, 30802, and 30930 in conjunction with 30130 or 30140. Performing middle turbinate surgery to вЂњgain accessвЂќ to the sinuses is not separately reported. It may be necessary to apend modifier 59 to 30802 when reported with 30930 to show separate procedures were performed. Text and Format В© 2013 KZA, Inc. 2013 AAPC_ENT Coding (KP)_032113 10 CPT only В© 2012 American Medical Association. All Rights Reserved Endoscopic Sinus Surgery CPT Code 31240 31254 31255 31256 31267 31276 31287 31288 Description Nasal/sinus endoscopy, surgical; with concha bullosa resection Nasal/sinus endoscopy, surgical; with ethmoidectomy, partial (anterior) with ethmoidectomy, total (anterior and posterior) Nasal/sinus endoscopy, surgical with maxillary antrostomy; with removal of tissue from maxillary sinus Nasal/sinus endoscopy, surgical with frontal sinus exploration, with or without removal of tissue from frontal sinus Nasal/sinus endoscopy, surgical with sphenoidotomy; with removal of tissue from the sphenoid sinus Remember: May separately report 31240 for endoscopic resection of concha bullosa when appropriately documented (e.g., pre-op diagnosis, CT scan findings). Otherwise, middle turbinate surgery is included in the endoscopic sinus surgery codes. вЂњRemoval of tissueвЂќ for 31267 and 31288 = polyps, mucocele, fungus ball; not вЂ“ вЂњdebris,вЂќ вЂњcontents,вЂќ mucous or pus. Do not report 31254 вЂ“ 31288 with the balloon dilation codes (31295-31297) for procedures on the same sinus. Report the above codes when tissue and/or bone is removed. All of the above codes include removal of nasal polyps from the same side at the same operative session; do not separately report 31237 (or 30110, 30115). Stereotactic Computer Assisted Navigation (SCAN) CPT Code 31295 31296 31297 Description Nasal/sinus endoscopy, surgical; with dilation of maxillary sinus ostium (eg, balloon dilation), transnasal or via canine fossa with dilation of frontal sinus ostium (eg, balloon dilation) with dilation of sphenoid sinus ostium (eg, balloon dilation) Coding Tips: Report above code when tissue is displaced. If tissue and/or bone is removed, then see codes 31254-31288. If tissue is both displaced and removed, then see codes 31254-31288. There is no current balloon technology for use in the ethmoid sinus; therefore, there is no ethmoid code. Beware: Some payors consider this вЂњexperimentalвЂќ or вЂњinvestigationalвЂќ and will not pay. This service may possibly be billed to the patient. Codes include fluoroscopy вЂ“ do not separately report 76000. Do not report 31295 in conjunction with 31233, 31256, or 31267 when performed on the same sinus. Do not report 31296 in conjunction with 31276 when performed on the same sinus. Do not report 31297 in conjunction with 31235, 31287, or 31288 when performed on the same sinus. Non-facility RVUs are high due to the practice expense incurred associated with purchasing the equipment. Although, the NF RVUs did decrease by almost half in 2012 (compared to 2011). Do not separately report a lavage code (31000, 31002) with the above codes. Text and Format В© 2013 KZA, Inc. 2013 AAPC_ENT Coding (KP)_032113 11 CPT only В© 2012 American Medical Association. All Rights Reserved Stereotactic Computer Assisted Navigation (SCAN) +61782 Stereotactic computer assisted volumetric (navigational) procedure, cranial, extradural (List separately in addition to code for primary procedure) AAO-HNS Policy on Intra-Operative Use of Computer Aided Surgery The American Academy of Otolaryngology вЂ“ Head and Neck Surgery endorses the intraoperative use of computer-aided surgery in appropriately select cases to assist the surgeon in clarifying complex anatomy during sinus and skull base surgery. There is sufficient expert consensus opinion and literature evidence base to support this position. This technology is used at the discretion of the operating surgeon and is not experimental or investigational. These appropriate, specialty specific, and surgically indicated procedural services should be reimbursed whether used by neurosurgeons or other qualified physicians regardless of the specialty. Examples of indications in which use of computer-aided surgery may be deemed appropriate include: 1) Revision sinus surgery. 2) Distorted sinus anatomy of development, postoperative, or traumatic origin. 3) Extensive sino-nasal polyposis. 4) Pathology involving the frontal, posterior ethmoid and sphenoid sinuses. 5) Disease abutting the skull base, orbit, optic nerve and carotid artery. 6) CSF rhinorrhea or conditions where there is a skull base defect. 7) Benign and malignant sino-nasal neoplasms. Documentation Requirements per American Rhinologic Society Include in the вЂњIndications for SurgeryвЂќ paragraph the medical necessity of need for stereotactic guidance. Document pre-op surgical planning including downloading and verifying images. Document registration of data. Document instrument calibration. Document Target Registration Error (TRE). Document anatomic localization and confirmation during surgery. Include вЂњendoscopicвЂќ approach and intra-operative computer findings. Tip: Be sure to document the need for use of navigational assistanceвЂ” this provides the medical necessity for the additional charge. Text and Format В© 2013 KZA, Inc. 2013 AAPC_ENT Coding (KP)_032113 12 CPT only В© 2012 American Medical Association. All Rights Reserved Endoscopic Sinus Surgery Cases 1. Procedure: Bilateral endoscopic maxillary antrostomies with tissue removal Detail: вЂ¦endoscope was used..the middle turbinate was medializedвЂ¦.the uncinate was noted to be without any polypoid changesвЂ¦a right-angle curette was utilized to forward-fracture the uncinate and the microdebrider was utilized to take down the uncinateвЂ¦this revealed evidence of polypoid changes at the maxillary sinus ostium causing occlusion of the ostium on the leftвЂ¦.microdebrider was utilized to remove the polypoid changes and a micropunch was utilized to widen the maxillary sinus ostium on the leftвЂ¦..same procedure performed on right sideвЂ¦. Choose the correct code combination: ___________ A B 31267 31256 31267-50 31256-50 2. Bilateral endoscopic total ethmoidectomies Bilateral endoscopic sphenoidotomies Bilateral endoscopic maxillary antrostomies with removal of polyps from within the maxillary sinuses Use of stereotactic navigation and image-guided system Choose the correct code combination: ________________ A B 31255 31255-50 31255-50 31267-50 31267-51 31287-50 31267-50 61782 31287-51 31287-50 61782 Text and Format В© 2013 KZA, Inc. 2013 AAPC_ENT Coding (KP)_032113 13 CPT only В© 2012 American Medical Association. All Rights Reserved Endoscopic Sinus Surgery Cases 3. Septoplasty, bilateral inferior turbinate submucous resections, bilateral endoscopic nasal polypectomies, bilateral endoscopic maxillary antrostomies and bilateral endoscopic anterior ethmoidectomies. Choose the correct code combination: ___________ A B 30520 30520 30140-51 30140-51 30140-50 30140-50 31254-51 31254-51 31254-50 31254-50 31256-51 31256-51 31256-50 31256-50 31237-59 31237-50, 59 4. Operative note reads: Balloon sinus ostia catheterization and dilation of both maxillary sinuses under fluoroscopy. There is no documentation of removal of bone and mucosa. Choose the correct code combination: ___________ A B 31256 31295 31256-50 31295-50 Text and Format В© 2013 KZA, Inc. 2013 AAPC_ENT Coding (KP)_032113 14 CPT only В© 2012 American Medical Association. All Rights Reserved Endoscopic Sinus Surgery Cases 5. Operative note reads: Bilateral endoscopic maxillary antrostomies using forceps and microdebrider for removal of bone and mucosa as well as balloon catheter sinus ostia dilation technology under fluoroscopy. Choose the correct code combination: ___________ A B 31256 31256 31256-50 31256-50 31295-51 31295-50 6. Bilateral endoscopic total ethmoidectomies, bilateral endoscopic maxillary antrostomies, bilateral outfracture and submucous resection of inferior turbinates, septoplasty Choose the correct code combination: __________ A B 30520 30520 30140-51 30140-51 30140-50 30140-50 31255-51 31255-51 31255-50 31255-50 31256-51 31256-51 31256-50 31256-50 30930-59 30930-50, 59 7. Septoplasty, endoscopic sphenoidotomy, and approach for neurosurgeon to remove a pituitary tumor. Choose the correct code combination: __________ A B 30250 62165-62 31287 Text and Format В© 2013 KZA, Inc. 2013 AAPC_ENT Coding (KP)_032113 15 CPT only В© 2012 American Medical Association. All Rights Reserved Snoring/Sleep Apnea Procedures In addition to the septoplasty, tonsillectomy and turbinate codes, the most common CPT codes used for insurance billed procedures include: CPT Description Code 21199 Osteotomy, mandible, segmental; with genioglossus advancement 21685 Hyoid myotomy and suspension 41512 Tongue base suspension, permanent suture technique 41530 Submucosal ablation of the tongue base, radiofrequency, one or more sites, per session 42145 Palatopharyngoplasty (e.g., uvulopalatopharyngoplasty, uvulopharyngoplasty) Global Period 90 90 90 10 90 Note: Many payors do not reimburse for 41512 or 41530. Obtain written prior authorization. RVU-NF for 41530 are high because the physician assumes the practice expense for performing the procedure (e.g., radiofrequency probe). DonвЂ™t forget to use separate diagnoses for these procedures such as turbinate hypertrophy, tonsillar hypertrophy, deviated septum, etc. Remember: Use an unlisted code (42299) for a LAUP (laser-assisted uvulopalatoplasty). Example Procedures performed: Septoplasty, Bilateral submucosal inferior turbinate reduction using radiofrequency, Coblation of the tongue base, Tonsillectomy, Uvulopalatopharyngoplasty Choose the correct code combination: ___________ A B 42145 30520-51 41530-51 42826-51 30140-52, 51 30140-52, 50 42145 30520-51 41530-51 42826-59 30802-51 Text and Format В© 2013 KZA, Inc. 2013 AAPC_ENT Coding (KP)_032113 16 CPT only В© 2012 American Medical Association. All Rights Reserved Ear Procedures TYMPANOSTOMY TUBE PLACEMENT Type of Anesthesia 69433 Local or topical 69436 General Codes may be reported bilaterally with modifier 50. CMS says: 10-day global period. Do not separately bill myringotomy вЂ“ itвЂ™s included in 69433/69436. Tube placement is included in a larger primary procedure performed on the same ear (e.g., tympanoplasty). Includes use of the microscope; do not separately report 92504 or 69990. Remember to use correct billing format as required by payor: o 69436-50 on one line versus 69436 and 69436-50 on two lines TYMPANOSTOMY TUBE REMOVAL 69424 - Ventilating tube removal requiring general anesthesia Code has a 0-day postoperative global period May be reported with modifier 50 if performed bilaterally Tube removed without general anesthesia may be reported with an E&M code, 92504 (binocular microscopy), or other appropriate code. It is not a вЂњforeign body removalвЂќ (69200-69205). Tube removal with another procedure on the same ear (e.g., perforation repair, tympanoplasty, mastoidectomy) is included in the larger primary procedure and not separately reported. Scenario: The surgeon who originally placed the tympanostomy (ventilating) tubes brings the patient to the outpatient facility. Under general anesthesia and utilizing an operating microscope, the surgeon creates a relaxing incision. The surgeon removes the tube with surrounding granulation tissue, thus creating an optimal situation for closure of the perforation in which the tube was situated. Monitoring of the ear in the office setting revealed the perforation to have closed within several weeksвЂ™ time. Scenario: Removal of a tympanostomy tube from the external auditory canal. Is this a вЂњforeign body removalвЂќ? No, it is not a foreign body removal. This is part of your E&M code when performed in your office; you may report 92504 if you use the microscope. If performed in the operating room, consider using 92502 (Otolaryngologic examination under general anesthesia). Append modifier 52 (reduced services) if a full ENT exam under anesthesia is not performed. Text and Format В© 2013 KZA, Inc. 2013 AAPC_ENT Coding (KP)_032113 17 CPT only В© 2012 American Medical Association. All Rights Reserved Ear Procedures FOREIGN BODY REMOVAL 69200 Removal foreign body from external auditory canal; without general anesthesia 69205 with general anesthesia Use for removal of items such as beads, insects, ear candling wax, etc.; do not use for removal of a tympanostomy tube. Includes use of the microscope; do not separately report 92504 or 69990. TYMPANIC MEMBRANE REPAIR CPT Code Description 69610 Tympanic membrane repair, with or without site preparation of perforation for closure, with or without patch 69620 Myringoplasty (surgery confined to drumhead and donor area) Comments May be reported with modifier 50 CMS says: 10-day global period Example: Freshening the edges of the perforated area of the tympanic membrane, paper patch graft May be reported with modifier 50 CMS says: 90-day global period A fat graft plug or a temporalis fascia graft may be placed medially to the eardrum Includes the harvesting of a donor graft when performed (do not separately report code such as 20926). The middle ear is not entered in this procedure Text and Format В© 2013 KZA, Inc. 2013 AAPC_ENT Coding (KP)_032113 18 CPT only В© 2012 American Medical Association. All Rights Reserved Ear Procedures TYMPANOPLASTY (Initial or Revision) CPT Description Code 69631 Tympanoplasty without mastoidectomy (including canaloplasty, atticotomy and/or middle ear surgery), initial or revision; without ossicular chain reconstruction 69632 with ossicular chain reconstruction (e.g., post fenestration) 69633 with ossicular chain reconstruction and synthetic prosthesis (e.g., partial ossicular replacement prosthesis [PORP], total ossicular replacement prosthesis [TORP]) Tips from CPT Assistant, August 2008: May be done transcanal or via a postauricular incision Graft harvest through a separate skin incision for repair/reconstruction may be reported separately (e.g., 20926). Codes require entry and inspection of the middle ear. Middle ear exploration (69440), exploratory tympanotomy, tube placement (69436), or membrane repair (69610) are not separately reportable. Scenario: IвЂ™m working on an appeal for a denial we received in 2012. Can you please help? We billed 69631 (transcanal tympanoplasty) and 20926 for harvesting a temporalis fascia graft. We also billed 69990, 95920 x 2 units (for 2 hours of intraoperative monitoring) and 95927 (somatosensory evoked potential study of the head and neck). We got paid on 69631 and 20926 but denied on the rest of the codes. Please help! Action: The intraoperative monitoring codes, 95920 and 95927, should not have been billed. Write off these charges. Intraoperative nerve monitoring was not separately billable for the surgeon in 2012 nor is it billable for the surgeon in 2013. CPT 69990 may or may not be reimbursed depending on payer policy; Medicare will not reimburse 69990 when billed with the auditory system codes. Text and Format В© 2013 KZA, Inc. 2013 AAPC_ENT Coding (KP)_032113 19 CPT only В© 2012 American Medical Association. All Rights Reserved Neck Dissection Neck Dissection CPT Codes 38700 Suprahyoid lymphadenectomy 38720 Cervical lymphadenectomy (complete) 38724 Cervical lymphadenectomy (modified radical neck dissection) Coding Tips 38700 = suprahyoid; involves removal of level I nodes only (CPT Assistant, August 2010). 38724 = modified radical or selective neck dissection (removal of lymph nodes in levels I - V; involves the removal of all lymph nodes routinely removed by radical neck dissection, while preserving the internal jugular vein, the spinal accessory nerve and/or the sternocleidomastoid muscle. Involves removal of more than level I nodes. 38720 = complete or radical; includes all five regions of the neck. In addition, the internal jugular vein, the spinal accessory nerve, and the sternocleidomastoid muscle are removed. It is appropriate to report a neck dissection code (e.g., 38724) with a direct laryngoscopy (e.g., 31525) if both are performed. The laryngoscopy is a separate diagnostic service and is not included in the neck dissection codes. Be sure to document lymph node removal. If the procedure is performed after radiation therapy has been delivered then be sure to document tissue removal. ALERT: There is no CPT code for only a вЂњneck dissectionвЂќ! Do not use a primary procedure code if it includes a radical neck dissection and youвЂ™ve done a modified radical neck dissection. Rather, report the primary code that does not include a neck dissection and separately report the modified radical neck dissection code(s). o Example: Laryngectomy with bilateral modified radical neck dissections Do DonвЂ™t 31360 Laryngectomy w/o RND 38724-59 MRND 38724-50, 59 MRND 31365 Laryngectomy w/RND 38724-59 MRND Text and Format В© 2013 KZA, Inc. 2013 AAPC_ENT Coding (KP)_032113 20 CPT only В© 2012 American Medical Association. All Rights Reserved Course Evaluation Please submit to the course instructor at the conclusion of the program. 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