Otolaryngology Coding Alert

Tip: Assume modifier indicator ‘0’ applies.

The latest rendition of Correct Coding Initiative (CCI) edits went into effect on Jan. 1, 2014, with more than 61,000 additions affecting virtually every medical specialty. There are too many changes applicable to otolaryngology practices to list everything here, but our summary will give you an idea of the scope.

Note: All otolaryngology edits in CCI 20.0 are classified as non-mutually exclusive, meaning you should not report both services in an edit pair on the same claim for work during the same patient encounter. They’re also known as comprehensive/component edits because one service inherently includes the other.

Be Careful of Consultative Services and Transitional Care Management

The hundreds of ENT edits are daunting on the surface – until you dig a bit and realize the majority focus on two areas of care.

The first group of codes applies to time spent on telephone or internet assessments and consultations:

• 99446 – Interprofessional telephone/Internet assessment and management service provided by a consultative physician including a verbal and written report to the patient’s treating/requesting physician or other qualified health care professional; 5-10 minutes of medical consultative discussion and review
• 99447 – … 11-20 minutes of medical consultative discussion and review
• 99448 – … 21-30 minutes of medical consultative discussion and review
• 99449 – … 31 minutes or more of medical consultative discussion and review.

These codes are new for 2014 and are intended to be used when your physician provides a consult by telephone or internet to another requesting provider. CCI specifies that the consults are inherent to many ENT services ranging in complexity from 30300 (Removal foreign body, intranasal; office type procedure) or 31510 (Laryngoscopy, indirect; with biopsy) to 40801 (Drainage of abscess, cyst, hematoma, vestibule of mouth; complicated) and 60260 (Thyroidectomy, removal of all remaining thyroid tissue following previous removal of a portion of thyroid).

You began reporting transitional care management (TCM) codes in 2013, but had to work your way around numerous coding edits introduced throughout the year. The same holds true for TCM codes this year: 

• 99495 – Transitional Care Management Services with the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge; Medical decision making of at least moderate complexity during the service period; Face-to-face visit, within 14 calendar days of discharge
• 99496 – … within 7 calendar days of discharge.

These codes are bundled into hundreds of ENT procedures just as the consultative services codes listed above.

A few specific examples of procedures you would report instead of TCM services include 42815 (Excision branchial cleft cyst, vestige, or fistula, extending beneath subcutaneous tissues and/or into pharynx), 69420 (Myringotomy including aspiration and/or eustachian tube inflation), and 92540 (Basic vestibular evaluation, includes spontaneous nystagmus test with eccentric gaze fixation nystagmus, with recording, positional nystagmus test, minimum of 4 positions, with recording, optokinetic nystagmus test, bidirectional foveal and peripheral stimulation, with recording, and oscillating tracking test, with recording).

Bottom line: Don’t automatically include one of the TCM or phone/internet consultation codes to a claim just because your physician provided the service and has supporting documentation. Chances are, CCI considers the service part of the wider-scope procedure your physician performed.

Check for the Modifier Silver Lining

CCI sometimes pairs two services as non-mutually exclusive (or comprehensive/component), but still allows you to report both services for an encounter – under certain circumstances. Most otolaryngology edits in CCI 20.0 can’t be unbundled, but always verify the pair’s modifier indicator to know whether separate reporting is possible.

Example 1: The edit bundling 99446 into 30310 (Removal foreign body, intranasal; requiring general anesthesia) carries a modifier indicator of “0,” so you cannot append a modifier to break the edit and report both services.

Example 2: The edit bundling 99495 into 40806 (Incision of labial frenum [frenotom]) carries a modifier indicator of “1.” You might be able to report both services from the same patient encounter together, if the services were for different reasons, different encounters or different sites and  your physician’s documentation demonstrates this. If so, you would append a modifier such as 59 (Distinct procedural service) to the bundled code. In this case, the modifier would be associated with 99495.

Resource: Check the complete CCI file on the CMS website to see which edits will apply to your practice. Log onto www.cms.gov and search for “CCI 20.0”. Edits under CCI 20.0 are effective from Jan. 1, 2014 until March 31, 2014.