Otolaryngology Coding Alert

"The notion that procedures should never be billed solely on the listed procedures at the top of the operative report is well established among coding specialists. Therefore, these specialists routinely recommend that coders read the entire operative note to accurately assess which procedures were performed and should be billed. This coding truism applies even more when the procedures performed were unusual or the procedures are not listed in the CPT manual.

Sometimes, however, the procedure notes in the operative report shed little additional light on what the otolaryngologist did. When dealing with insufficient or weak documentation, coders have two options: the otolaryngologist can be asked to provide an addendum to the operative note or the operative session must be billed based on the documentation available.

In the case study that follows, the otolaryngologist lists a bilateral tympanostomy as well as a partial myringectomy on the right side. There is no code for excising part of the tympanic membrane and because the otolaryngologist does not clarify how the excision related to the placement of tubes in the same ear, the coder may have difficulty selecting the correct codes when billing for the session.

Operative Report

Procedures: Bilateral myringotomy with ventilation tube placement, adenoidectomy and partial myringectomy of the left tympanic membrane.

Preoperative Diagnosis: Persistent eustachian tube dysfunction, chronic mucoid otitis media and adenoid hypertrophy.

Postoperative Diagnosis: Same

Indications: This is a 2-1/2-year-old white male who has had persistent eustachian tube problems and had a previous set of ventilation tubes to treat recurrent bouts of acute otitis media. Since those tubes have extruded, the patient has redeveloped a tendency for persistent middle ear fluid, retraction of the tympanic membrane and recurrent otitis media episodes. The patient is brought to surgery at this time for replacement of ventilation tubes. The weakened portion of the tympanic membranes may have to be addressed by partial myringectomy. The adenoid pad is to be removed because of the statistical advantage in cases of multiple sets of ventilation tubes.

Description of Procedure: There was a large amount of cerumen and debris that was aggregated around an extruded ventilation tube. The tube and the surrounding debris were removed. The tympanic membrane was intact, with ballooning of the anterior superior portion of the tympanic membrane outwardly under the influence of nitrous oxide. The area in question is severely atrophic. When the myringotomy was made this area became quite redundant. Decision made to resect the weakened area. This left approximately a 15 percent anterior superior tympanic membrane perforation. An Activet T-gromet ventilation tube was modified by removing the outer flange with the tab and one-third of the inner flange on the same side. This flange was directed superiorly to allow it to fit without pressure. Gentamycin ophthalmic drops were instilled.

The same procedure was performed on the left. The anterior portion of the tympanic membrane was relatively atrophic but not atrophic to the extent that partial resection was necessary. A simple myringotomy opening was made. Both middle ears contained a mild amount of mucoid fluid that was aspirated. The middle ear mucosa was edematous and mildly erythematous, indicating poor eustachian tube functioning.

A Crowe-Davis retractor was placed so as to maximally expose the oropharynx. The tonsils were found to be normal, juvenile in size, and without inflammation. The adenoid pad was palpated to be moderate in size. It was removed using adenoidal curets and an adenoid punch. Residual adenoid tissue was found around the eustachian tube openings. This was removed in a piecemeal fashion. Adenoidal packs were placed for a period of five minutes, after which no significant bleeding was encountered. The nasofrontal sites were irrigated from anteriorly into the oropharynx to remove clots and to establish choanal patency. No further bleeding was encountered

Based on the documentation, this operative session would be coded as follows, says Lee Eisenberg, MD, an otolaryngologist in Englewood, N.J., and a member of CPTs editorial panel and executive committee:

69436 tympanostomy (requiring insertion of
ventilating tube), general anesthesia

69436-50 ; bilateral procedure

42830 adenoidectomy, primary; under age 12

The correct diagnosis codes are 381.81 (eustachian tube dysfunction), 381.20 (chronic mucoid otitis media) and 474.12 (adenoid hypertrophy). The first two codes should be linked to the bilateral tympanostomy, whereas the adenoid hypertrophy is associated with the 42830.

Carrier policies vary regarding the use of one or two lines for claims with modifier -50 (bilateral procedure) attached. Most Medicare carriers instruct providers to use only one line, as follows: 69436-50.

But in this case, the patient is 2 years old (i.e., a non-Medicare patient) and many private payers still want to see two lines for bilateral claims. Make sure you know which method your payer wants because its computer may not recognize claims filed the other way.

Not Documented Means Not Done

There is no CPT code for a partial myringectomy. Although the otolaryngologist excised a portion of the tympanic membrane (TM) and listed the TM excision among the procedures performed, this service as described in the operative report probably would not be reimbursed separately because the excision was not performed on its own, Eisenberg says.

Partial excisions of the tympanic membranes often are performed during myringotomies and tympanoplasties, Eisenberg says, and usually are associated with one of these procedures. In this case, based on the documentation, Eisenberg believes the atrophic section of the tympanic membrane was flaccid, so the otolaryngologist removed the flaccid section and placed the tubes through the now-enlarged incision.

The only other likely possibility is that the flaccid section of the eardrum was excised, after which the tympanic membrane was repaired and the tube re-inserted via a second incision in a healthy area of the TM, says Eisenberg. If that were the case, 69610 (tympanic membrane repair, with or without site preparation or perforation for closure, with or without patch) could be billed.

This operative note, however, does not identify that such a repair took place or that a separate incision was performed, Eisenberg says. Because the operative note appears to indicate that the tube was placed through the already existing hole in the eardrum and makes no mention of any repair, only the bilateral tympanostomy is billable, he says.

The operative note does not describe how tympanic membrane excision was performed, so a medical director at the insurer reviewing it will likely determine that the otolaryngologist only spent a moment or two excising the flaccid portion of tympanic membrane and conclude that the procedure is incidental to the reinsertion of the tube, he says. This is usually the case, Eisenberg adds.

In either scenario (bilateral tympanostomy or tympanostomy on one side and tympanic repair on the other), the partial myringectomy, or eardrum excision, is considered incidental and therefore does not qualify as an unlisted procedure that may be reported separately, Eisenberg concludes.

The TM excision is incidental because the operative note suggests it was performed to improve access for the tube, says Randa Blackwell, a coding specialist with the department of otolaryngologist at the University of Maryland in Baltimore. When the tube is placed, normally the TM would retract, but the area surrounding the earlier incision has atrophied and become flaccid. So the flaccid area is excised to aid the current tube insertion. The excision is performed to the same end as a TM incision during a normal tympanoplasty that is a bundled component of the procedure, much like debridement (described in the notes but not listed as a separate procedure at the top of the op report).

Blackwell notes, With myringotomies and tympanostomies, there is no question of separate payment for debridement. The same principles apply for services performed to improve access.

Attaching modifier -22 (unusual procedural services) to the right tympanostomy is not an option because there is nothing in the documentation to suggest that the excision took an unusual amount of time or significantly increased the risk to the patient, Blackwell adds.

In short, as described, the procedure, including the TM excision, still qualifies as a regular tympanostomy and should be billed accordingly.

Finding Section Would Be Useful

The documentation in this operative note does not justify an increased billing, agrees Eisenberg, who notes the absence of both a detailed description of the TM excision and, just as important, an explanation of why the excision was performed. With an operative note like this, a coder should be cautious and bill less rather than more.

Eisenberg suggests the billing for this operative session would have been greatly clarified had the operative note included a Findings section that explained what the otolaryngologist found (atrophied, flaccid tympanic membrane), what was performed (partial excision of the TM) and why it was performed (to facilitate placement of the PE tube).

Alternatively, if the TM was repaired and an incision created elsewhere on the TM, the section again would include what the otolaryngologist found, explain what was done (tympanic membrane repair, as well as a separate incision elsewhere) and explain why the decision to repair the TM and create another incision elsewhere was made.
A Findings section is even more useful for scenarios (unlike this case study) in which sufficient time and/or risk has been documented to justify coding for an unlisted procedure or attaching modifier -22 to the appropriate procedure code."