Otolaryngology Coding Alert

When two or more procedures are performed by a physician in the office on the same day, they are categorized as multiple procedures. Otolaryngologists often perform two or more procedures the same day, and billing them correctly can be deceptively complicated.

At first glance, billing for multiple procedures would not appear to be all that difficult. CPT 1999 clearly indicates that modifier -51 (multiple procedures) should be attached to any additional procedure when multiple procedures, other than Evaluation and Management (E/M) services, are performed at the same session by the same provider. CPT goes on to say that the primary procedure or service may be reported as listed. The additional procedure(s) or services may be identified by appending the modifier -51 to the additional procedure or service codes.

Medicare requires the use of modifier -51 for secondary procedures when you have different procedures on the same day, says Emily Hill, PA-C, the managing partner of Strategic Healthcare Services and a member of the American Medical Associations Relative Value Update Committee, representing the American Medical Associations Health Care Professionals Advisory Committee Review Board. Hill also serves on the AMAs CPT-5 Project and Correct Coding Policy committees.

However, modifier -51 does not cover all scenarios involving multiple procedures. Some are bundled to primary procedures with global periods, while others may be entirely distinct from the primary procedure. Furthermore, some third-party payers differ from Medicare guidelines that mandate modifier -51 for most multiple procedures.

In addition, there are 85 procedures listed in
Appendix F of CPT 1999 that are exempt from modifier
-51, as are add-on services that are always done in conjunction with other procedures, which have had their value already reduced.

Note: Most carriers will reimburse a procedure with an attached -51 modifier at a 50 percent rate.

Coding a Typical Multiple Procedure

In the following case, the patients pre-op diagnosis was serous otitis and tonsillectomy and adenoidectomy (T&A) hypertrophy; in the post-op report, a large retropharyngeal lymph node was added. The otolaryngologist excised the retropharyngeal lymph node, performed a bilateral tympanotomy and tube, as well as a T&A.

According to the operative note:

The patient had enlarged adenoids and huge tonsils but when we removed the tonsils there was a large mass in the retropharyngeal space just to the right of the midline. At first I thought it was an anomalous carotid artery but on palpitation there was no pulsation. It was a round moveable mass, fairly firm. I suspected it was a lymph node but it could have been some kind of neurogenic tumor or something of that nature. We elected, while we were there, to go ahead and excise it. We simply extended the tonsil incision and developed a retropharyngeal flap and dissected out a lymph node that was about 11/2 cm in diameter. It seemed benign. It was smooth. It did not look like a tumor. We sent it as a separate specimen. I closed the retropharyngeal flap to the posterior edge of the tonsil incision with interrupted chromic sutures. The bleeding was minimal. There was no sign of any large vessels, such as a carotid artery, in the area. She tolerated the procedure well... [and] was returned to the recovery room in good condition...I will recheck her in the office in two weeks...We will call the mom if the path report shows anything alarming but I suspect it will be a benign reactive lymph node.

If the patient is under 12, says Teresa M. Thompson, CPC, an ENT coding consultant from Carlsborg, WA, the T&A should be billed 42820 (tonsillectomy and adenoidectomy; under age 12). Then we can assume the tubes were put in place to treat the chronic serous otitis media, so that procedure should be coded 69436 (tympanostomy [requiring insertion of ventilating tube], general anesthesia), with a -50 modifier (bilateral procedure) attached because the procedure is bilateral. Then you would code for the excision of the lymph node, using 38500 (biopsy or excision of lymph node(s); superficial [separate procedure]); or 42804 (excision of nasopharynx, visible lesion, simple), depending on whether the node was superficial or deep. The codes should be listed as follows: If the lymph node was deep, 69436-50, 42820-51, and 42804-59-51. If the lymph node was superficial, there would be no separate charge for the excision. Code 38500 is designated as a separate procedure, and would likely be denied as incidental to the more comprehensive procedure.

All the codes noted above would be listed highest value first based on RVUs. If the lymph node was deep, the
69436-50 would be listed first, followed by 42820-51, then 42804-59-51. If the lymph node were superficial, the codes would be listed as follows: 69436-50 and 42820-51.

In another example, a physician removes cerumen from a patient (69210, removal impacted cerumen [separate procedure], one or both ears), and also performs a laryngoscopy (31505, laryngoscopy, indirect [separate procedure], diagnostic) to look at her vocal cords.

According to CPT and HCFA guidelines, modifier -51 should be used on the 69210, because it has fewer RVUs than the 31505. Code 69210 would then be paid at 50 percent.

Note: The number of RVUs for any given procedure can be found in the Federal Register.

Distinct and Individual Procedures

Sometimes physicians perform multiple procedures on the same day that are distinct and individual. Although there is a strong rationale that distinct procedures performed on the same day should be reimbursed at 100 percent, HCFA guidelines stipulate that modifier -51 must be used unless the procedures are exempt from modifier -51.

Some commercial carriers, meanwhile, tell physicians not to use modifier -51, Thompson says. Instead, they prefer all procedures performed on the same day to be listed from highest to lowest RVU value.

Under certain circumstances, however, the physician can indicate that a procedure was distinct or independent from other services performed on the same day by using modifier -59 (distinct procedure service), which is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances.

According to CPT 1999: This may represent a different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician. However, when another already established modifier is appropriate, it should be used rather than modifier -59. Only if no more descriptive modifier is available, and the use of modifier -59 best explains the circumstances, should modifier -59 be used.

Modifier -59s major use is to unbundle procedures included together in a global period, Thompson says. If you just put the two CPT codes in, and one code is included with the other one, you have to explain why you coded that way.
Based on this definition, using modifier -59 on code 38500 would be incorrect, since the scenario was not a significant separate procedure, different organ system, separate incision or lesion.

A scenario where modifier -59 would be appropriate concerns removal of same-size cancerous facial lesions on the same day using different methods for each, says Hill.
This can be confusing because there are at least three scenarios with entirely different coding strategies. Had the physician removed the lesions using the same method, such as excision, (11640-11646, excision, malignant lesion, face, ears, eyelids, nose, lips; lesion diameters range from 0.5 centimeters or less to more than 4.0 cm) or shaving (11310-11313, shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameters range from 0.6 to more than 2.0 cm), a 3 should be listed in the units column to the left of the code to indicate the number of lesions. Had the physician also used a method such as cryotherapy to remove some of the lesions, the payer may interpret this as a bundled service (cryotherapy used in conjunction with excision on the same lesion). The payer will not pay for using two or more methods to remove one lesion. But if the patient had several lesions removed by various methods, it would be appropriate to designate each lesion with a -59 modifier.

Thompson adds that some third-party payers are reimbursing only one procedure and bundling everything else, irrespective of whether modifiers -51 or -59 are attached.

She says the best way to ensure being paid for all procedures is to provide different, specific diagnoses for each individual procedure, accompanied by appropriate documentation.