Otolaryngology Coding Alert

Usually, an otolaryngologist operating alone will perform an endoscopic dacryocystorhinostomy (DCR). On occasion, however, an ophthalmologist may also be present during the operative session. Coding such a situation can be difficult because, according to the HCFA fee schedule, neither cosurgery (modifier -62) nor assistant surgery (modifier -80) should be coded when 31239 (nasal/sinus endoscopy, surgical; with dacryocystorhinostomy) is billed.

DCR reduces or eliminates tearing or recurrent infections of the lacrimal system of the eye. The procedure involves the construction of a new pathway for tears to exit the eye by way of an incision along the side of the nose that creates an opening in the nasal bone.

When DCR is performed endoscopically, dilators and/or a light probe is passed through the duct and small tubes, or stents, may also be inserted into the two drainage points of the eye and passed through the opening in the bone and into the nose.

Endoscopic DCR has significant advantages over external DCR, including absence of facial scarring. The patient may also require additional endoscopic procedures to treat inflamed sinuses or turbinates, which may be contributing to lacrimal problems.

Some otolaryngologists may not feel comfortable catheterizing the lacrimal system and may request that an ophthalmologist perform these functions, says Sanford Archer, MD, an otolaryngologist and associate professor at the University of Kentuckys College of Medicine in Lexington, Ky., chair of the Patient Safety and Quality Improvement Committee of the American Academy of Otolaryngology Head and Neck Surgeons (AAO-HNS) and a member of the academys Rhinology and Paranasal Sinus Committee.

When this occurs, coding and billing the operative session depends on the documentation in the operative report, which should be carefully examined to determine precisely what procedures each surgeon performed, as illustrated below.

Operative Report

Preoperative Dx: Obstructed left nasolacrimal system

Postoperative Dx: Obstructed left nasolacrimal system, sinus polyposis

Procedure: Endoscopic DCR on the left and a left anterior ethmoidectomy

Indications: 65-year-old male with a history of extensive sinus polyposis has had multiple sinus procedures and allergy shots in the past. He has had obstructive nasolacrimal system with chronic epiphora that has been refractory to [an ophthalmologist]s best medical management. He presents now for an endoscopic DCR on the left.

Procedure: The patient was brought to the operating room, placed under general endotracheal anesthesia. The ophthalmologist placed antibiotic drops in the left eye and probed the left lacrimal duct with serial dilators and then a light probe. I examined the nose endoscopically. He had extensive polyposis in the anterior ethmoid and cicatrix and scar along the lateral wall of the nose. The light probe could not initially be identified due to the covering polyposis. This was removed with the microdebrider after the area had been injected with 2% Xylocaine 1:100,000 Epinephrine. The endoscope lights were turned down and the light probe was visualized in the nose. Very hard bone was removed from the anterior lacrimal crest. The light probe could be more clearly seen. The incision was made into the duct area and a large stent was passed into the lacrimal duct and into the nose. The sac was opened as widely as possible. We could see both the entrance areas of the upper and lower cannula. The Silastic tubing was brought out into the nose and tied with heavy silk and shortened. The ethmoid cavity on the left contained extensive polyposis superiorly. This was removed with a microdebrider and the cavity was packed temporarily with Afrin-soaked neuropledgets. All pledgets were removed. Antibiotic ointment was applied. The patient was extubated without event and brought to the recovery room in good condition.... Final procedures performed were endoscopic DCR on the left for a blocked nasal lacrimal system and an anterior ethmoidectomy on the left for nasal sinus polyposis. There was no evidence of entry of the orbital cavity or cranial vault.

Medicares ruling that neither modifier -62 nor -80 may be appended to 31239 may be driven by the reality that, in most cases, otolaryngologists perform the procedure on their own but it may also have been influenced by the specific nature of the endoscopic DCR itself.

The DCR is the opening up of the lacrimal sac into the nasal cavity by creating a hole in the bone that overlies the duct [sac], Archer says. Passing the light through the duct and stenting are not necessarily part of the DCR procedure. He notes that the passing of dilators and/or a light probe through the duct to pinpoint where the DCR should be performed is a separate clinical service. Similarly, the insertion of stents, which is performed when the hole created by the DCR requires additional support to drain properly, is also distinct from the DCR.

Therefore, the correct coding for the operative session is as follows, Archer says:

31239; and
31254 nasal/sinus endoscopy, surgical; with ethmoidectomy, partial [anterior].

Because he or she was not involved in the DCR, the ophthalmologist should bill for the insertion of the stent only (68815, probing of nasolacrimal duct, with or without irrigation; with insertion of tube or stent).

Note: Light probe insertion is included in 68815.

The operative note clearly states that the otolaryngologist also performed a partial ethmoidectomy. Because chronic ethmoid sinusitis (473.2) is specifically documented as the reason for the ethmoidectomy, 31254 is separately payable, says Randa Blackwell, a coding and reimbursement specialist with the department of otolaryngology at the University of Maryland in Baltimore. The ethmoidectomy and the reason for it are well documented in the otolaryngologists operative note.

Blackwell adds that 473.2 should be linked to 31254 on the HCFA 1500 claim form, whereas 375.56 (stenosis of nasolacrimal duct, acquired) is associated with the DCR.

Billing Issues

According to Blackwell, the main billing issue presented by the operative report is whether the ophthalmologist is entitled to bill for the probe, or if the service is incidental to the DCR. Although the national Correct Coding Initiative does not bundle the probe or stenting of the lacrimal duct with 31239, some carriers may determine that the probe/stent is inclusive because these services are so frequently performed with 31239. Therefore, before billing for two surgeons performing separate components of the operative session, contact your carrier and explain why both surgeons are required.

For example, if the ophthalmologist refers a patient to the otolaryngologist for DCR and is then asked to assist in the procedure, the ophthalmologist may not be able to bill for his or her role in the operative session, Blackwell says. She notes, Just because another surgeon is there and did something does not guarantee payment.

In this case, she says, the probe and stent placement were performed to facilitate the DCR, which many carriers may consider incidental. Others, meanwhile, may determine that the lacrimal probe and stent should be paid separately.

This may affect the otolaryngologist because without a distinct procedure to bill, the ophthalmologist also may bill for the DCR. Therefore, the otolaryngologist should contact his or her counterpart at the ophthalmology practice and jointly decide how to bill the operative session. Otherwise, a race may result in which only the first DCR bill to arrive at the carrier is reimbursed.