Otolaryngology Coding Alert

Break down the report into its respective surgical components.

Being a coder for an ear, nose, and throat (ENT) provider requires a mastery of each of the aforementioned anatomic sites. While your surgeon(s) may specialize in one particular area, you should be familiar with — and capable of — coding any ENT surgical case that hits your desk.

Today, you’ll get a detailed analysis of how to code an operative report involving tracheoesophageal speech prosthesis and rigid esophagoscopy with biopsy. As you’ll see, the key lies within separating out the operative report in order to delegate CPT^® codes accordingly.

Refine your tracheoesophageal speech prosthesis coding skills with the following clinical example.

Hone in on Coding-Relevant Portion of Surgery

First, have a look at the surgeon’s exam header for each respective component of the procedure:

1. Dilation of tracheoesophageal puncture and hypopharynx using a bougie dilator
2. Placement of tracheoesophageal speech prothesis
3. Rigid esophagoscopy with biopsy

Now, let’s break the operative report into three individual components. Have a look at the first part of the procedure, which includes some preparation in addition to notes pertaining to various aspects of the patient’s condition:

Part 1: Once an adequate level of sedation was achieved, the laryngectomy stoma was visualized, and the tracheoesophageal speech prothesis was removed. The patient had previously undergone multiple dilations, steroid injections, tract debridement of granulation tissue and Botox^® injections due to malfunctioning speech prothesis. However, none of these interventions were successful in returning his normal esophageal speech.

If you’re not used to coding placements and replacements of tracheoesophageal speech prostheses, then you may have a difficult time interpreting portions of the operative note. First, the physician identifies the surgical hole created in the neck known as a stoma. The stoma is the result of a previous total laryngectomy, which included the removal of the patient’s voice box. This stoma is the route of insertion the surgeon will use to remove the previously existing voice prosthesis and replace it with a functioning device. As you can see, the surgeon outlines the numerous attempts at treating the malfunctioning prosthesis before resorting to a complete replacement. 

Here, you’ve got to make sure to filter out the information that’s not necessarily pertinent to assigning the correct CPT^® codes. While the context surrounding the need for a new voice prosthesis is important, it’s not relevant to your duties as a coder.

Report Codes for Dilation, Prosthesis Placement

Next, evaluate the portion of the operative report that involves the esophageal dilation and subsequent tracheoesophageal prosthesis placement:

Part 2: After removing the 12mm prothesis, I assessed the tract, and there was no significant amount of granulation tissue. I could visualize the esophageal lumen. I then passed a hypopharyngeal bougie dilator through the stoma and advanced it to dilate both the tracheal as well as the esophageal lumen. The dilator was then removed, and I placed a #12 speech prothesis without difficulty, and I could feel the inner flange. There was approximately a 1- or 2-mm excess length of the prothesis, so I removed the 12 mm and I placed the 8 mm prothesis, which also engaged within the inner lumen of the esophagus without difficulty.  In order to confirm placement of the inner flange, I then performed a rigid esophagoscopy.

Following the removal of the malfunctioning prosthesis, the physician evaluates the vocal tract for any tissue or debris impeding access to the esophageal lumen and trachea. The surgeon then documents the dilation of the lumen and trachea using a hypopharyngeal bougie dilator. The bougie dilation process is a technique used by the surgeon to widen the esophagus in preparation for placement of the new prosthesis. The surgeon first makes an attempt at positioning a 12 mm prosthesis before resorting to an 8 mm-sized prosthesis that fits more comfortably within the inner lumen of the esophagus. Before diving into the next portion of the operative note, you’ll want to outline what CPT^® codes are available to report so far.

For the dilation of the esophageal lumen, you should report code 43450 (Dilation of esophagus, by unguided sound or bougie, single or multiple passes). This code fully encompasses the dilation the surgeon performed, so no modifier is necessary. Next, you need to know why you should not consider reporting the voice prosthesis using 31611 (Construction of tracheoesophageal fistula and subsequent insertion of an alaryngeal speech prosthesis (eg, voice button, Blom-Singer prosthesis)) with modifier 52 (Reduced Services).

First, make note of the portion of the operative report detailing that the surgeon is not creating a new tracheoesophageal fistula, but rather working within the confines of the previously performed voice prosthesis placement that included the creation of a tracheoesophageal fistula. In the current surgical scenario, the surgeon’s job is easier in that they are simply removing the existing prosthesis without making any underlying incision into the neck.

“Although it may seem appropriate to code the replacement of the prosthesis as 31611 with modifier 52, there is a concern that the placement of the prosthesis is a very small component of the total CPT^® code 31611, while the creation of the tracheoesophageal fistula involves the more significant portion of the CPT^® code,” explains Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, AAPC Fellow, of CRN Healthcare in Tinton Falls, New Jersey. “Based on this division, it is hard to justify applying modifier 52 to 31611 for the replacement of the prosthesis. Therefore, you should code the change of a voice prosthesis using the unlisted code 31899 (Unlisted procedure, trachea, bronchi).

Confirm Separate Rigid Esophagoscopy Code With NCCI Check

Finally, have a look at the remaining portion of the operative reporting documenting the rigid esophagoscopy:

Part 3: A small rigid esophagoscope was passed into the oral cavity after the upper gums were protected with a gauze pad. As I advanced the esophagoscope into the hypopharynx, I noted a 1cm exophytic lesion on the posterior wall. Photodocumentation and a biopsy are obtained. I then advanced the scope to the level of the tracheoesophageal prothesis, and I could visualize the inner flange engaged within the esophageal lumen and there was no deformity of either the prosthesis tune or the flange. The esophagoscope was then removed.

A rigid esophagoscopy is not included in the work for the replacement of the voice prosthesis. You’ll find no existing National Correct Coding Initiative (NCCI) edits exist between 43454, and the code for a rigid esophagoscopy, 43193 (Esophagoscopy, rigid, transoral; with biopsy, single or multiple). This code also includes the biopsy the surgeon performed on the documented lesion. Since the surgeon documents no complications with the placement of the inner flange of the prosthesis, you can confirm that the three existing codes you have in place are correct.