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 crystal-clear, says John Fink, MD, an otolaryngologist at Dearborn Ear, Nose and Throat in Michigan. -The ENT's report should state what he did to start and where he stopped, stating what the neurosurgeon then did.- Show your surgeons the difference in reimbursement their documentation makes, he says.

Clarify Who Performed the Approach

Because the otolaryngologist dictated part of the above op note in passive voice (as most op reports are), it does not specifically indicate which surgeon performed the orbitocranial zygomatic approach. Nonetheless, the two surgeons seemed to work together on the approach, with the neurosurgeon making the osteotomy cuts and removing the orbital zygomatic bar, and the ENT performing the orbital exenteration and elevating the periosteom.

Best bet: Obtain the neurosurgeon's op report so you have both distinctive reports to work from, says Andrew Borden, CPC, CCS-P, CMA, reimbursement manager in the department of otolaryngology at Medical College of Wisconsin in Milwaukee. -If the ENT works at a hospital, etc., you should have access to both op reports and vice versa. This documentation would alleviate some of the mystery as to who participated in the approach and who participated in the excision.-

Try sorting this out before the surgery. Agreement between the two parties is not always easy, unless some sort of discussion occurs between the two doctors before the case begins, Borden says.

Why does it matter? Suppose the ENT and the neurosurgeon both report the approach using 61592 (Orbitocranial zygomatic approach to middle cranial fossa [cavernous sinus and carotid artery, clivus, basilar artery or petrous apex] including osteotomy of zygoma, craniotomy, extra- or intradural elevation of temporal lobe) with no modifiers appended. The surgeon who submits his claim first will collect the roughly $3,000 that Medicare reimburses for this code. The surgeon whose claim arrives last would collect nothing for the service.

The solution: -Typically, each surgeon is going to code the main procedure with modifier 62,- says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, charge capture manager for the University of Washington Physicians in Seattle.

The ENT and the neurosurgeon should each report 61592-62. And each surgeon must submit a separate op note describing his distinctive work, says Annette Grady, CPC, CPC-H, CPC-P, CCS-P, an independent healthcare consultant and American Academy of Professional Coders professional medical coding curriculum instructor and workshop educator.

As long as Medicare considers the specific CPT code allowable with modifier 62, the carrier will reimburse each surgeon 62.5 percent of the allowable for the code. In this case, each physician would collect about $1,875 for the approach.
 
Use No Modifier on Individual Portions

 The op report indicates that the neurosurgeon excised the tumor away from the sinus. Because the neurosurgeon states that he opened the dura to isolate the tumor, you should use a code for an intradural tumor excision. The neurosurgeon should report 61608 (Resection or excision of neoplastic, vascular or infectious lesion of parasellar area, cavernous sinus, clivus or midline skull base; intradural, including dural repair, with or without graft) for this  service, says Julie Keene, CPC, an otolaryngology coding and reimbursement specialist at University ENT Specialists in Cincinnati.

For the otolaryngologist's work removing the tumor from the maxillary sinus, you should assign 31230 (Maxillectomy; with orbital exenteration). Because the ENT performs this procedure alone, you won't need to append modifier 62, Bucknam says.

But Borden disagrees with the likelihood that both surgeons performed separate excisions of a single tumor. -The tumor went intradural, therefore the more extensive intradural code should be a co-surgery between the two doctors,- meaning the ENT would report 61592-62 and 61608-62, he says.

Don't Overlook Reporting Graft

Double-check the ENT's op note for a graft. Because the skull area doesn't have a lot of fat to harvest, the otolaryngologist probably harvested the fat graft from another site, such as the abdomen in this type of case, Keene says. For separately harvesting the graft, she suggests reporting 20926 (Tissue grafts, other [e.g., paratenon, fat, dermis]) in addition to 61592-62 and 31230.

Although you are billing two procedures, you may not need to use modifier 51 (Multiple procedures). -Our carriers do not require it,- Keene says. California coders, beware: Your carrier, National Heritage Insurance Company (NHIC), requires modifier 51.