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OTOLARYNGOLOGY
CODING
CLIPS
Sponsored by:
y of
American Academy
Professional Coders
(AAPC)
Nashville, Tennessee
June 9, 2010
Presented by:
Mary LeGrand, RN, MA, CCS-P, CPC
2
AGENDA
 Surgical
Package Definition
CPT®
 Medicare
 Modifiers
 Balloon Sinuplasty
p y
 Endoscopic Sinus Surgery
 Turbinate Procedures
 Endoscopic Skull Base Procedures
 Neck Dissections
 Ear Coding

SURGICAL PACKAGE
DEFINITION
3
4
WHAT IS INCLUDED IN THE SURGICAL
PACKAGE ACCORDING TO CPT®?
WHAT IS INCLUDED IN THE SURGICAL
PACKAGE? CPT® VS. MEDICARE
CPT®
Subsequent to the decision for surgery, one related E&M
encounter on the date immediately prior to or on the date of
procedure (including history and physical).
 Immediate postoperative care, including dictating operative
notes, talking with the family and other physicians
 Writing orders
 Evaluating the patient in the post-anesthesia recovery area
 Postoperative pain management including catheter placement
by operating surgeon
 No mention about the number of days included in follow-up
 Typical postoperative follow-up care
5
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1
WHAT IS INCLUDED IN THE SURGICAL
PACKAGE? CPT® VS. MEDICARE
WHAT IS INCLUDED IN THE SURGICAL
PACKAGE? CPT® VS. MEDICARE
Follow Up Care for Diagnostic Procedures:
F/up care for diagnostic procedures (i.e.,
arthroscopy) includes only that care related to
recovery
y from the diagnostic
g
procedure.
p
Care of
the condition for with the diagnostic procedure
was performed or of other concomitant
conditions is not included and may be reported
separately.
Follow-Up Care for Therapeutic Surgical
Procedures: F/up care for therapeutic surgical
procedures includes only that care which is
usually
y a part
p of the surgical
g
service.
Complications, exacerbations, recurrence, or the
presence of other diseases or injuries requiring
additional services should be separately reported
(CPT vs. Medicare).
7
WHAT IS INCLUDED IN THE SURGICAL
PACKAGE ACCORDING TO MEDICARE?
Medicare
E&M in which the decision is made is separately billable. Visits to perform
history and physicals are not separately reportable.
 Discussion with patient/family about the nature of the procedure,
alternative treatment risks, benefits and other informed consent issues
 Scheduling surgery
 Writing preoperative admission notes and orders
 Dictating the operative record
 Writing postoperative orders and postoperative prescribed care
 Postoperative pain management including catheter placement by
operating surgeon
 Major procedure has a global period of 90 days
 Minor procedure has a global period of 0 or 10 days
 Follow-up care including treatment of complications unless they
require a return to the operating room for the prescribed follow-up period
8
WHAT IS INCLUDED IN THE SURGICAL
PACKAGE? CPT® VS. MEDICARE
GLOBAL DAYS


Minor procedure = Zero or ten days
Major procedure = Ninety days
CPT®
Medicare
Postoperative pain management including Postoperative pain management including
catheter placement by operating surgeon catheter placement by operating surgeon
No mention about the number of days
included in follow-up
Typical postoperative follow-up care
Major procedure has a global period of 90
days
Minor procedure has a global period of 0 or
10 days
Follow-up care including treatment of
complications unless they require a return
to the operating room for the prescribed
follow-up period
9
10
MODIFIER 24
Modifier 24
Unrelated Evaluation And
Management Service By The Same
Physician During A Postoperative
Period
KEY MODIFIERS
Report E&M service for unrelated
E&M and link modifier 24 to the
appropriate E&M CPT® code.
Link ‘unrelated’ diagnosis to the
E&M service.
Monitor accounts receivable for
payment of full allowable.
Appeal inappropriate denials.
11
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How Did You Code This Scenario?
Service Description
Modifier
Example:
Physician performs and
documents an E&M service on
a patient seen in follow up for
ear pain three weeks following
a total thyroidectomy.
12
2
MODIFIER 25
Modifier 25
Significant, Separately Identifiable
Evaluation And Management Service
By The Same Physician On The
Same Day Of The Procedure Or Other
Service
Typically appended to an E&M
Service on the same day as a minor
procedure.
May need to append to unrelated
E&M on same day as care if billing
non manipulative codes.
Attach modifier 25 to E&M services
only.
MODIFIER 57
How Did You Code This Scenario?
Service Description
Modifier 57
Modifier
Decision for Surgery
Report with an E&M service when
the E&M service results in the
decision for surgery, typically the
day of or day before a major
p
procedure.
Example:
Physician performs and
documents an E&M service
on a patient seen for new
complaints of hoarseness. The
physician also performs a
flexible fiberoptic
laryngoscopy as he is unable
to fully visualize the larynx.
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MODIFIER 26: PHYSICIAN
INTERPRETATION
Attach modifier 57 to E&M services
only.
 Used
when you do the
professional or
interpretive service
ONLY
15
WRITTEN REPORTS
How Did You Code This Scenario?
Service Description
Modifier
Example:
Physician performs and documents
an E&M service on a non Medicare
patient seen who is seen in the ER
at the request of the ER physician
for evaluation of a “hot” parotid
mass. The physician takes the
patient emergently to the OR for a
complex I&D of the parotid gland.
14
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MODIFIER 26: PHYSICIAN
INTERPRETATION
Ultrasonic guidance for needle placement (e.g.,
biopsy, aspiration, injection, localization device),
imaging supervision and interpretation
CPT®
76942
RVU
5.04
76942-26
0.94
76942-TC
4.10
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16
WRITTEN REPORTS:
OTHER CPT® GUIDELINES
Special Report: 2010
2008 CPT®: Results, Testing, Interpretation, and Report
A service that is rarely provided, unusual, variable,
or new may require a special report. Pertinent
information should include an adequate definition or
description of the nature, extent, and need for the
procedure; and the time, effort, and equipment
necessary to provide the service.
Results are the technical component of a service. Testing leads
to results; results lead to interpretation. Reports are the work
product of the interpretation of test results. Certain procedures
or services described in the CPT® codebook involve a
technical component (e.g., tests), which produce results (e.g.,
data, images, slides). For clinical use, some of these results
require interpretation. Some CPT® descriptors specifically
require interpretation and reporting to report that code.
AMA
 Since 1997…
 In the radiology section
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3
MODIFIER 50
Modifier 50
Bilateral Procedures
MODIFIER 51
How Did You Code This Scenario?
CPT® Code
Modifier
Watch reimbursement closely!
May use RT/LT modifiers if payor
(e.g., Medicare) accepts.
DO NOT attempt to Add-on or
Modifier 51 exempt services.
Example:
Physician performs and
documents bilateral
endoscopic maxillary
antrostomy for sinus disease.
NOTE: Payors may vary on
claim form submission.
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MODIFIER 59
Modifier 59
Distinct Procedural Service
Used to tell the payor that this is a special
circumstances and procedure is distinct or
independent and are not ordinarily reported
together but are appropriate under circumstances
that might be considered bundled but you met the
“special requirement” qualifying for payment…
 different session,
 different p
procedure or surgery,
g y
 different site or organ system,
 separate incision/excision,
 Separate injury (or area of injuries in extensive
injuries),
 for Medicare use only if more specific modifier
(RT, LT) will not work.
Submit your full fee for each procedure
(unless payor requires you to submit a reduced
fee) and list in descending value order.
Decreases reimbursement by 50%
100% first procedure 50% 2nd, 3rd, 4th, 5th
(Medicare Multiple Procedure Payment Formula).
Used when you return the patient to an
approved operative suite to treat a
complication.
p
 Unplanned return.
Attach to the subsequent unplanned surgical
procedure.
Protects reimbursement for subsequent
procedure during global period.
Global period STAYS with the original case.
Submit your full fee for each procedure
(unless payor requires you to submit a
reduced fee) and put in descending
value order.
Example:
E
l
Physician performs and documents a
flexible fiberoptic laryngoscopy in
the office and also performs removal
of impacted cerumen from both ears.
Decreases reimbursement by 50%
100% first procedure, 50% 2nd, 3rd, 4th,
5th (Medicare Multiple Procedure
Payment Formula).
NOTE: Medicare may not require
use of Modifier 51.
NOTE: An E&M service is not
addressed in this scenario.
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MODIFIER 58
CPT® Code
Modifier 58
Modifier
Staged Or Related Procedure Or
Service By The Same Physician
During The Postoperative Period
Used when you are doing a subsequent
procedure that was:
1. Planned or anticipated (staged) OR
2. More extensive than the first OR
3. Therapy following a surgical
procedure.
Example:
Physician dictates right total
ethmoidectomy and left partial
anterior ethmoidectomy.
Attach to the subsequent surgical
procedure.
Protects reimbursement for subsequent
procedure during global.
NOTE: Other surgical
procedures performed at the
same setting, not addressed if
applicable.
How Did You Code This Scenario?
CPT® Code
Modifier
E
Example:
l
Right modified neck
dissection during the global
period of an excisional
biopsy of cervical lymph
node.
Global period RESETS with the date of
the subsequent case.
21
MODIFIER 78
Unplanned Return to the
Operating/Procedure Room by the Same
Physician Following Initial Procedure for a
Related Procedure During the
Postoperative Period
Modifier
How Did You Code This Scenario?
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Modifier 78
How Did You Code This Scenario?
CPT® Code
Used to tell the payor you did an
additional reportable procedure (stand
alone procedure) under the same
anesthesia.
Used to identify the second of
bilateral procedures unless a carrier
specifically requires a different format.
Complete the boxes on the CMS
1500 form dependent on carrier
policy.
Modifier 51
Multiple Procedures
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MODIFIER 79
How Did You Code This Scenario?
CPT® Code
Modifier
Example:
Return to the operating room
ten days post tonsillectomy
and adenoidectomy for
control of post operative
hemorrhage.
Reimbursement is reduced to 50-70% of
allowable charge.
Only necessary if the subsequent surgery is
within the global period.
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Modifier 79
Unrelated
Procedure Or Service By The Same
Physician During The Postoperative
Period
Use when the patient has a procedure in the
post-op period that is unrelated to the original
procedure.
1. Not for complications
2. Must have a different diagnosis and make
it the primary diagnosis
Protects procedure from being bundled into
the global surgical package.
Only necessary if the subsequent surgery is
within the global period.
Attach modifier 79 to the unrelated procedural
service.
If the new surgical procedure has a ten or
ninety day global period, there will be
simultaneous global periods to track.
Expect reimbursement to be at 100% of the
allowable.
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How Did You Code This Scenario?
CPT® Code
Modifier
Example:
Right endoscopic ethmoid
and maxillary sinus
debridement one week
post op endoscopic right
maxillary and ethmoid
surgery and
septorhinoplasty.
24
4
ENDOSCOPIC VS. BALLOON
SINUS SURGERY
ENDOSCOPIC VS. BALLOON
SINUS SURGERY
From the January 2010 CPT® Assistant:
 Q: Using a balloon under endoscopic control, a dilation of the frontal
sinus ostium is performed. Is this reported as a 31276 (Nasal/sinus
endoscopy, surgical with frontal sinus exploration, with or without
removal of tissue from frontal sinus)?
Note:
The AAOHNS is working on new CPT® codes for
the balloon catheter sinus ostia dilatation
procedures.
Therefore,
an unlisted
d
Th
f
li d CPT® code
d iis
recommended when bone and/tissue is not removed
during the procedure.

25
ENDOSCOPIC SINUS SURGERY
CODING TIPS




26
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USE OF +61795
Intra-Operative Use of Computer Aided Surgery
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
Report one CPT® code per sinus
To report CPT® code “with tissue removal”, must
document: Removal of tissue such as polyps or
mucocele, not “debris,” mucous or pus
Separately report 31240 for endoscopic resection
of concha bullosa when appropriately
documented (e.g., pre-op diagnosis, CT scan
findings)
Nasal polypectomy is included in endoscopic
sinus surgery on the same side, same session
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A: No
No. The correct code to report for this service is 31299 (Unlisted
procedure, accessory sinuses); this includes fluoroscopy, if concurrently
performed. However, if a balloon were used endoscopically, along with
cutting tools such as curettes and forceps, to create a sinusotomy by
removal of tissue from the frontal sinus ostium (and the interior of the
sinus, if performed), then 31276 should be reported. In this latter
instance, the balloon dilation is inconclusive/incidental to the frontal
sinus exploration and should not be separately reported. Similar coding
logic would apply to creating of endoscopic maxillary antrostomies and
sphenoid sinusotomies.
27
CODE THESE SINUS CASES: #1
28
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CODE THESE SINUS CASES: #1
Choose the correct code combination:
Physician Dictates:
Septoplasty, bilateral inferior turbinate submucous
resections, bilateral endoscopic nasal
polypectomies, bilateral endoscopic maxillary
antrostomies and bilateral endoscopic anterior
ethmoidectomies
A
30520
B
30520
C
30520
D
30520
30140-51
30140 50
30140-50
30140-51
30140-59
31254-51
30140 50
30140-50
30140 50 59
30140-50,59
31254 50
31254-50
31254-51
31254-51
31237-59
31237-51
31254-50
31254-50
31237-50,59
31237-50
31256-51
31256-51
31256-59
31256-51
31256-50
31256-50
31256-50
31256-50
31237-59
31237-50,59
29
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5
CODE THESE SINUS CASES: #2
CODE THESE SINUS CASES: #2
Choose the correct code combination:
Physician Dictates:
Bilateral endoscopic maxillary antrostomies with
removal of polyps from within the maxillary
sinus, bilateral endoscopic total thmoidectomies,
and endoscopic resection of a left concha bullosa
A
31255
B
31254
C
31255
D
31255
31254-50
31254-50
31255-50
31267-51
31267-51
31267-51
31267-51
31267-50
31267-50
31267-50
31267-50
31254-51
31240-51
31240-59
31240-51
31240-51
Note: May need 59 on 31240
31
TURBINATE PROCEDURES
CPT Code Description
30200
Injection into turbinate(s), therapeutic
▲30801 Ablation, soft tissue of inferior turbinates,
unilateral or bilateral, any method (e.g.,
electrocautery, radiofrequency ablation, or
tissue volume reduction); superficial
▲30802
intramural (i.e., submucosal)
30930
30130
30140
31240
2009: intramural
Fracture nasal inferior turbinate(s),
therapeutic
Unilateral/ Bilateral
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32
TURBINATE PROCEDURES
Global Days
Unilateral or Bilateral
0
Unilateral or Bilateral
10
 Do
not report 30801 with 30802
in 2010: Deleted from below 30140 - (For
reduction of turbinates, use 30140 with modifier 52)
 When reporting
p
g a submucous resection CPT 30140,,
the documentation should indicate the mucosa was
entered/incised and preserved. A statement such as
“excised the turbinate(s)” is not sufficient to
accurately take into account the submucous resection
of the inferior turbinate(s), thus would not support
reporting CPT® code 30140
 Revised
Unilateral or Bilateral
10
AAOHNS says:
Unilateral or Bilateral
10
Excision inferior turbinate, partial or
complete, any method
Submucous resection inferior turbinate,
partial or complete, any method
Nasal/sinus endoscopy, surgical; with
concha bullosa resection
Medicare says:
Unilateral
Unilateral
90
Unilateral
90
Unilateral
0
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33
TURBINATE PROCEDURES
not report CPT® codes 30801, 30802, and 30930
with CPT® codes 30130 or 30140
 Performing middle turbinate surgery to “gain access”
to the sinuses is not separately reported (e.g. middle
turbinate surgery is included in all endoscopic sinus
surgery on the same side, except if there is a
separately, identifiable concha bullosa)
 CCI edits may require modifier 59 on 30802 when
reported with 30930
 Do
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34
ENDOSCOPIC PROCEDURES:
PITUITARY TUMOR EXCISION AND
SKULL BASE SURGERY
62165: Neuroendoscopy, intracranial; with excision of
pituitary tumor, transnasal or trans-sphenoidal
 All codes include the approach, tumor resection
and closure, including dural repair
 Do not report septoplasty or sinus surgery codes
separately
 Report as co-surgery with modifier 62 when
sharing “code” with neurosurgery
NOTE: There are no endoscopic skull base codes thus ENT
uses 31299 as appropriate.
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6
NECK DISSECTION CODING
Neck Dissection CPT Codes
38700 Suprahyoid lymphadenectomy
38720 Cervical lymphadenectomy (complete)
38724 Cervical lymphadenectomy (modified radical neck dissection)
+38746 Thoracic lymphadenectomy, regional, including mediastinal and peritracheal
nodes (List separately in addition to code for primary procedure)
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
38724 = modified radical; 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
38700 = suprahyoid (also called supraomohyoid); a variation of modified
radical neck dissection that includes removal of nodes from specific
limited or extended regions within the neck. Involves removal of
cervical lymph nodes from specific limited or extended regions
within the neck – anything less than all five levels
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37
THYROIDECTOMY/ PAROTIDECTOMY
NECK DISSECTIONS
AND
LARYNGECTOMY/GLOSSECTOMY AND
NECK DISSECTION
CPT®
Code
31360
31365
31390
31395
41140
Description
Laryngectomy; total w/o RND
Laryngectomy; total w/ RND
Pharyngolaryngectomy w/RND; w/o reconstruction
with reconstruction
Glossectomy; complete or total, with or without
tracheostomy, without radical neck dissection
41145 Glossectomy; complete or total, with or without
tracheostomy, with unilateral radical neck
dissection
41150 Glossectomy; composite procedure with resection
floor of mouth and mandibular resection, without
radical neck dissection
38
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EXAMPLE: H/N PROCEDURE WITH
NECK DISSECTION
Physician Dictates:
Total laryngectomy and bilateral modified neck
dissections
Thyroidectomy /ND CPT® Codes/Description
60252 Thyroidectomy, total or subtotal for malignancy; with
limited neck dissection
60254
with radical neck dissection
How Did You Code This Scenario?
Parotidectomy /ND CPT® Codes/ Description
42410 Excision of parotid tumor or parotid gland; lateral lobe,
without nerve dissection
42415
lateral lobe, with dissection and preservation of facial
nerve
42420
total, with dissection and preservation of facial nerve
42425
total, en bloc removal with sacrifice of facial nerve
42426
total, with unilateral radical neck dissection
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CPT® Code
39
EAR CODING: INTRATYMPANIC/
TRANSTYMPANIC INJECTIONS
40
95992 Canalith repositioning procedure(s) (e.g.,
Epley maneuver, Semont maneuver), per day
When Performed by the Physician
 Medicare will deny payment if you report
95992 due to code payment indicator of “I”
(69801 includes all required infusions performed
on initial and subsequent days of treatment)
 Report, as appropriate the drug (e.g., J1580 for
injection, Garamycin, gentamicin, up to 80 mg;
J1020-J1040 for methylprednisolone)
 Myringotomy is inclusive to this procedure

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EAR CODING:
CANALITH REPOSITIONING
69801 Labyrinthotomy, with or without cryosurgery
including other nonexcisional destructive procedures
or perfusion of vestibuloactive drugs (single or
multiple perfusions); transcanal
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Modifier
41
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42
7
EAR CODING: CERUMEN REMOVAL
EAR CODING:
CANALITH REPOSITIONING
69210: Removal impacted cerumen (separate
procedure), 1 or both ears
G0268: Removal of impacted cerumen (one or both
ears) by physician on same date of service
as audiologic function testing
When Performed by the Audiologist or Other Qualified
Personnel (Not a Therapist)
 Medicare will deny payment because audiologists are
paid under the “other diagnostic tests” category and as
such will not be paid for therapeutic procedures
When Performed by a Therapist (e.g., PT)
 Medicare instructs physical therapists to report 97112,
or another “more generally defined ‘always therapy’
codes.”
Note: Other payors policies may vary.
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43
EAR CODING: CERUMEN REMOVAL
 A diagnostic
G0268
What if cerumen is not impacted?
1. not reportable
2. 69210
3. part of E&M
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45
procedure is included in a definitive
surgical code and not separately reported.
Example: 92504, separate procedure is a diagnostic
test and would not be reported with cerumen
removal.
 When multiple procedures on the ear are
performed, generally you will report the “highest”
or most definitive procedure. For example, report
only the removal of a foreign body CPT® code
when you remove cerumen and a foreign body
from the same ear.
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EAR CODING:
PROCEDURE CODING TIPS
EAR CODING:
PROCEDURE CODING TIPS
 CPT®
 Middle
69620 (fat graft myringoplasty) includes the
graft harvest – do not separately report this activity
 Otherwise, graft harvest through a separate incision
may be separately reported (e.g., 20926)
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44
EAR CODING:
PROCEDURE CODING TIPS
How to report removal of impacted cerumen?
 69210 or
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46
ear exploration (69440) is included in
middle ear surgical codes (e.g., tympanoplasty,
mastoidectomy, stapedectomy, oval/round window
fistula repair) and not separately reported.
 Meatoplasty (69310) is designated by CPT® as a
“separate procedure” and not separately reported.
47
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48
8
EAR CODING:
PROCEDURE CODING TIPS
 There
THANK YOU!
CPT®
is no
code for examination of the ears
under anesthesia. CPT® 92502 states
“Otolaryngologic examination under general
anesthesia” – this is interpreted to mean ears, nose
and throat. If no other ENT procedure performed
on the patient, you may be able to use 92502-52 if
only the ears are examined.
 Tube removal is reported only when performed
under general anesthesia in the OR (CPT® 69424).
Tube removal in the office is included in your
E&M code.
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