Otolaryngology Coding Alert

Consider every last detail, down to the number of HCPCS units.

There’s no better way to improve your clinical coding skills than working your way through an example that’s seemingly out to trip you up every step of the way. However, there’s more than one way in which an operative report can cause you trouble from a coding perspective.

In the following example, you’ll encounter a few unexpected challenges that result from a suboptimal operative report procedure breakdown. For inexperienced otolaryngology coders, there’s more than enough here to lead you astray.

Work your way through the following example and avoid a few key pitfalls along the way.

Discern Between Sinus Tracts, Cavities

Example: One of our providers administered steroid injections to help shrink cysts in patient’s sinus tracts and help close the tracts. Altogether, the doctor injected a 1.5 cc mixture comprised of 1 cc Kenalog 40 mg and 0.5 cc of lidocaine into all four of the patient’s sinus cavities along with a second entry into one of the cavities for a total of five injections.

Semantics is the most important consideration in this question if you want to get the coding right. You see a reference to both sinus cavities and sinus tracts, which are distinctly unique anatomical sites. According to Dorland’s Illustrated Medical Dictionary, a sinus tract is “a pathological passage in the body resembling a fistula but open at only one end; it may later develop infection that drains through the tract.” On the other hand, a sinus cavity is what you typically envision when you’re discussing one of the four accessory sinuses.

You’ll find that code 20500 (Injection of sinus tract; therapeutic (separate procedure)) exclusively applies to sinus tract injections in which a provider will inject a therapeutic agent that connects a wound or formed abscess to the skin. However, on a side note, besides the fact that 20500 is not the correct code for the procedure, keep in mind that you want to consider medically unlikely edits (MUEs) before appending a number of units to a given code. Code 20500 has an MUE of 2, meaning only two units may be reported on a given date of service (DOS). However, it’s also got a bilateral surgery indicator of “0,” meaning that you should not consider billing for the service bilaterally. This means that in the instance that you do report code 20500, you should know that you will typically only report one unit per physician encounter — with a maximum of two distinct physician encounters being billable per DOS.

Now you want to determine what the correct CPT^® code is to report a series of steroid and lidocaine injections into the sinus cavities. While this isn’t highlighted in the question, it’s important to confirm that the physician performed this procedure endoscopically. When beginning your search, you may encounter the following option to consider:

• 96372 (Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular)

While this looks like a potential match based on the code description, the injection into a sinus cavity does not meet the criteria for a subcutaneous or intramuscular injection. Furthermore, 96372 is typically designated for injections through the skin. You’ll ultimately find no existing code in the CPT^® book that meets the description of this procedure. Therefore, you’ll have to resort to 31299 (Unlisted procedure, accessory sinuses). You’ll see that 31299 is designated an MUE of 1, so do not report more than one unit. Furthermore, you should not append any laterality modifiers to 31299.

Finding a comparison code for this service is not particularly easy. If the physician performs the injections via endoscope, the most practical comparison code will be 31237 (Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement (separate procedure)).

Billing advice: “You should also make note that in Box 19 of the CMS-1500 form that ‘five sinus injections were performed via endoscopy with 1.5cc Kenalog 40mg and 0.5cc of lidocaine,’” advises Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, of CRN Healthcare in Tinton Falls, New Jersey. “Furthermore, you don’t want to forget to bill for the Kenalog 40mg. Kenalog’s generic name is triamcinolone acetonide,” Cobuzzi explains. The HCPCS code options for Kenalog are:

• J3300 (Injection, triamcinolone acetonide, preservative free, 1 mg)
• J3301 (Injection, triamcinolone acetonide, not otherwise specified, 10 mg)
• J3304 (Injection, triamcinolone acetonide, preservative-free, extended-release, microsphere formulation, 1 mg)

Without any specification as to whether the Kenalog is preservative-free, you are advised to report code J3301. You may report 1 cc of Kenalog 40 mg as J3301 x 4 units. However, since the documentation indicates 1.5 ccs, you’ll instead multiply 4 units of J3301 by 1.5. This results in a total of 6 units of J3301.