Otolaryngology Coding Alert

2 Ways You May Report Laryngectomy With MRND

Published on Wed Mar 16, 2005

Find out why experts back billing both 31365 & 31360/38724-59

Weigh the reasons some real-world ENT coders bill a laryngectomy and a modified radical neck dissection (MRND) as a single code (31365) while others report the procedures as two codes (31360 and 38724-59).

No Code Describes Larynx Removal and MRND

Unlike the total laryngectomy codes (31360, Laryngectomy; total, without radical neck dissection; 31365, Laryngectomy; total, with radical neck dissection), CPT lacks a code that combines a laryngectomy with an MRND.

"The total laryngectomy codes describe either a laryngectomy without radical neck dissection (31360) or with radical neck dissection (31365)," says Andrew Borden, CCS-P, CPC, CMA, reimbursement manager in the Department of Otolaryngology and Communication Sciences at Medical College of Wisconsin in Milwaukee.

Case study: When an otolaryngologist performs a total laryngectomy without neck dissection (31360) and also does a cervical lymphadenectomy (MRND) (38724, Cervical lymphadenectomy [modified radical neck dissection]), coders aren't sure whether they should bill both codes, says Robin M. McCabe, CPC, surgery specialist coder at Southern Illinois University School of Medicine in Springfield. "Should I use modifier -59 (Distinct procedural service) on 38724?" she asks.

While 31360 and 38724-59 is a possibility, another coding option also exists -rolling the codes into 31365.

Here are the pros and cons of each.

Option 1: Separately Report Each Procedure

Because no code describes a laryngectomy with MRND, you could separately bill the operations. "You could split out the procedures," Borden says.

Method 1 Unilateral MRND. You would bill:

31360 - Total laryngectomy without RND

38724-59 - Cervical lymphadenectomy (MRND).

Method 1 Bilateral MRND. If the otolaryngologist performs a laryngectomy and bilateral cervical lymphadenectomy, you could assign:

31360 - Total laryngectomy without RND

38724-50-59 - Bilateral cervical lymphadenectomy (MRND).

Editor's note: When reporting bilateral claims, you may have to use two lines or double your fee depending on the insurer.

Coding MRND Is Technically Correct

Because no code describes a laryngectomy with radical neck dissection, breaking out the codes is technically correct. "A MRND has a significantly different work value than an RND," says Randa Blackwell, coding specialist at The 33rd Street Surgery Center in Baltimore.

In addition, the MRND is a completely different procedure from the laryngectomy. "The MRND is a significant, separate procedure that the total laryngectomy codes don't include," Blackwell says.

31360/38724 Payment Hinges on Insurer

But insurers may include the MRND code 38724 in the laryngectomy code 31360. The National Correct Coding Initiative (NCCI), version 11.0, bundles 38724 into 31360, so payers' computer systems may incorporate the edit.

Out: For Medicare, you can use modifier -59 to break the bundle. "The NCCI edits allow a modifier to override the 38724 and 31360 bundle," Borden says.

Private payers may or may not require modifier -59 on 38724 with 31360. "I use modifier -59, depending on the insurer," Blackwell says.

But even with modifier -59, some insurers won't reimburse an MRND with a laryngectomy. "Payers may not allow 38724 with 31360," Borden says. On 31360/38724-59 claims, some insurers combine the procedures into 31365 and pay on that code.

Option 2: Bill 31360/38724 as 31365

Because insurers often roll 31360 and 38724 into 31365, some coders adopt this reporting method. "Although the laryngectomy with neck dissection code describes a radical dissection, not a modified radical, it can be frowned upon to bill the modified radical," says Barbara Cobuzzi, MBA, CPC, CPC-H, an otolaryngology coding and reimbursement specialist and president of Cash Flow Solutions, a physician billing firm in Brick, N.J.

Here's how you would combine the laryngectomy and MRND procedures:

Method 2 Unilateral MRND. If an otolaryngologist performs a laryngectomy with an MRND, you could report:

31365 - Total laryngectomy with radical neck dissection.

Method 2 Bilateral MRND. When the surgeon does a laryngectomy with MRND on the right side and an MRND on the left side, you would bill:

31365-RT - Total laryngectomy with neck dissection

38724-59-LT - MRND.

Modifier -59 Is a Hard Sell

Coders commonly bill the laryngectomy with neck dissection code for the laryngectomy and MRND and bill an MRND appended with modifier -59 for the additional dissection, Cobuzzi says.

They report 31365/38724-59 "even though more accurate coding would be a laryngectomy without neck dissection (31360) and 38724-50-59," Cobuzzi says.

Why: You'll have a hard time convincing an insurer to pay on the initial MRND. When you report 38724-50-59, you're using modifier -59 to describe separate sites.

Problem: "The MRND is not a separate site," Cobuzzi says. The otolaryngologist performs the laryngectomy in a U-shape and horizontally extends the incision in either direction for an MRND.

31365 Pays About $56 Less Than Combo Claim

If you report 31365 instead of 31360 and 38724-59, your bottom line won't suffer too much. "There's a minimal relative value unit (RVU) difference between the laryngectomy with neck dissection code and separately billing the laryngectomy and MRND," Borden says.

Payment: Code 31365 nationally reimburses at $1,762.23 (46.50 RVUs). Medicare pays 31360 (35.17 RVUs; $1,332.86) and 38724 (25.66 RVUs; $972.45) at a national rate of $1,819.09 (with multiple-procedure rules, Medicare would reimburse 38724-59 at 50 percent or $486.23). Reporting 31365 instead of 31360, 38724-59 cuts $56.86 from your claim.