Otolaryngology Coding Alert

When two surgeons work together to perform a complicated procedure, they bill the procedure codes with modifier -62 (two surgeons). But when each performs distinct aspects of the surgery that are unrelated, the modifier is unnecessary, allowing each physician to be reimbursed fully for the code billed.

The following operative session involved multiple procedures and repairs on a 68-year-old white male with a history of right-sided facial paralysis. He was found to have a malignant neoplasm involving the right parotid gland and right temporal bone. He now presents for a right lateral skull base procedure. Two physicians, an otolaryngologist and a neuro-otologist, performed the procedures. Both doctors dictated separate operative reports.

Diagnoses: Squamous cell carcinoma of the right lateral skull base (parotid gland and temporal bone); complicated open wound/defect ear and temporal bone.

Operations Performed: Preauricular infratemporal approach to the lateral skull base including right modified neck dissection; lateral skull base resection (parotidectomy) and right partial temporal bone resection; reconstruction of lateral skull base (using skin graft, abdominal fat graft and temporalis myogenous flap).

Procedures Performed

This operation involved a number of procedures described in separate op notes dictated by both physicians. The notes are too lengthy to be reproduced here, therefore a summary of the procedures performed is provided.

The first part of the procedure was the approach to the lesion. The otolaryngologist exposed the lateral skull base, allowing additional exposure of the parapharyngeal space and deep aspect of the parotid gland, pterygoid musculature and infratemporal fossa and lateral skull base. The otolaryngologist then identified, dissected and mobilized the internal jugular vein, spinal accessory nerve and occipital artery. This provided further exposure of the skull base.

Attention was then turned to the neck, where the otolaryngologist isolated the parotid gland and temporal bone. Resection of these structures followed.

The otolaryngologist then performed a modified neck dissection: (1) to help with exposure and approach to the right lateral skull base; and (2) to remove lymph nodes from the neck that were at risk for spread of metastatic disease from the malignant neoplasm in the parotid gland.

A neck dissection at different levels was completed.
At this point, the otolaryngologist turned his attention to the lateral skull base resection, where a cut was made superiorly down through the subcutaneous tissue, temporalis fascia and parotid gland at the level of the zygoma.

A partial lateral temporal bone resection was performed by the neuro-otologist. A conventional mastoidectomy was performed under high-power magnification after the neck dissection and radical parotidectomy. The microscope also was used during the resection of the lateral temporal bone to preserve the neurovascular structures and avoid injuries to them.

The otolaryngologist then started reconstruction by using a split-thickness skin graft from the right thigh for reconstruction of the ear canal and temporal bone defect. The fat graft was taken from the left lower quadrant of the abdomen.

The split-thickness skin graft was placed on top of the temporalis muscle and sutured to the margins of the ear canal, the defect, with a running absorbable suture.

Coding the Procedure

This operative session should be billed using the following codes, says Lee Eisenberg, MD, an otolaryngologist in Englewood, N.J., and a member of the American Medical Associations CPT editorial panel and executive committee.

The Otolaryngologist
61590infratemporal preauricular approach to middle cranial fossa (parapharyngeal space, infratemporal and midline skull base, nasopharynx). with or without disarticulation of the mandible, including parotidectomy, craniotomy, decompression and/or mobilization of the facial nerve and/or petrous carotid artery

38724cervical lymphadenectomy (modified radical neck dissection)

15732muscle, myocutaneous, or fasciocutaneous flap; head and neck (e.g., temporalis, masseter, sternocleidomastoid, levator scapulae)

15120split graft, face, scalp, eyelids,
mouth,neck,ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq. cm or less, or one percent of body area of infants and children (except 15050)

15770graft; derma-fat-fascia

The Neuro-otologist
69535resection temporal bone, external approach

69990use of operating microscope (list separately in addition to code for primary procedure)

The mastoidectomy would not be coded because it is considered incidental to the 69535, Eisenberg says, adding that the temporal bone resection takes a 69535 rather than a 69970 (removal of tumor, temporal bone) because the surgeons did not use a prima fossa approach but rather a lateral approach. The middle fossa approach is through the skull, Eisenberg says, and approaches the temporal bone from above rather than from the side, as was done in this session.

The parotidectomy performed is part of the approach code 61590, says Margaret M. Hickey, MS, MSN, RN, the clinical director of the Tulane Cancer Center in New Orleans, La., and president of the Society of Otorhinolaryngology and Head-Neck Nurses.

According to Hickey, 61590, rather than 42426 (excision of parotid tumor or parotid gland; total, with unilateral radical neck dissection), should be used, together with the radical neck dissection (38724). She maintains that 61590 more accurately defines the procedure that actually was performed. Hickey also notes that it is the squamous cell of the temporal bone that ties these particular procedures together in this situation.

Modifier -62 Not Recommended

Neither surgeon should bill any of these procedures with a modifier -62, says Teresa Thompson, CPC, an otolaryngology coding and reimbursement specialist in Karlsborg, Wash. She recommends using modifier -62 when the procedures performed by the surgeons are defined by only one CPT code. In a session like this one that includes several procedures with their own CPT codes, however, surgeons should bill only for the procedures they perform and use the assistant modifier for any of the other procedures they took part in.

Each doctor did individual procedures. The neuro-otologist just did the temporal bone, so he should just bill for that, Thompson says.

To bill for the assists, each surgeon should attach modifier -80 (assistant surgeon) to the codes for the procedures in which they helped the other surgeon.

Note: The operative report from the surgeon billing for any given procedure must document that the assistant surgeon was present and working as an assistant. No documentation from the assistant surgeon is required.