Otolaryngology Coding Alert

ENT's portion requires specification, individual documentation When your otolaryngologist works as a co-surgeon on a complex procedure, you had better nail down the documentation perfectly -- and the other physician's practice had better follow the same rules. Otherwise, your 62.5 percent co-surgery payment could go up in smoke.

Sometimes the otolaryngologist will work alongside another surgeon, and modifier 62 (Two surgeons) won't be necessary, but other times they will share a procedure that falls under the same CPT code. See if you can spot the problems with the following op report that could cause dollars to be left on the table.

Preoperative diagnosis: Recurrent right cavernous sinus inferotemporal fossa maxillary region meningioma.

Procedure overview: The otolaryngologist performed an orbitocranial zygomatic approach and maxillectomy with orbital exenteration.
 
Follow the Surgeon's Notes The pertinent details of the op note follow: The initial incision was made from the root of the zygoma extending across the temporal and frontal regions, terminating just behind the hairline at the midline. The periosteum was stripped from the overlying bone, and using the Midas Rex drill, a right frontal temporal craniotomy flap was created and removed to allow elevation of the periosteum from the orbital roof. Osteotomy cuts were made in the standard orbital zygomatic fashion, allowing removal of the entire orbital zygomatic bar in one piece.

I then performed the orbital exenteration, increasing the room into the subfrontal and cavernous sinus region. The periosteum was elevated off the middle fossa floor, and the middle meningeal was identified and coagulated. The tumor was evident near the temporal tip region. The dura over the temporal tip was gradually opened, isolating the tumor away from the temporal lobe.

The neurosurgeon gradually mobilized the tumor away from the sinus, allowing identification of the pituitary gland, which could be followed up to its stalk. These were protected with moistened Gelfoam and cottonoids, allowing further removal and mobilization of the sinus portion of the tumor and the portion going to the maxillary
sinus, which was amputated at this point with the CUSA, allowing complete mobilization and removal of the cavernous sinus temporal tip region of the tumor and the tumor which had been mobilized all in one block.

I then proceeded with removal of the portion of the tumor into the maxillary sinus region. Following placement of drainage system, plates, screws and a fat graft, the neurosurgeon proceeded with closure. Get a Second Op Note We presented the above case to top clinical and coding experts, who produced no less than five different answers. The varied responses underscore the importance of receiving both op -- the one from the otolaryngologist shown above and the one from the neurosurgeon.

Encourage your surgeons to make their co-surgery op reports [...]