Otolaryngology Coding Alert

Eighty-eight surgical procedures make up components of 31296.

Mind your edits when coding new codes for endoscopy, stereotaxis, and destruction in your otolaryngology practice this 2011. National Correct Coding Initiative (NCCI) Edits 17.0 -- which took effect Jan. 1 -- prohibits simultaneous reporting of:

• 31295-31297 (Sinus endoscopy) and 263 other procedures;
• 31634 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with balloon occlusion, with assessment of air leak, with administration of occlusive substance [e.g., fibrin glue], if performed), and 17 other procedures;
• 61782 (Stereotactic computer-assisted [navigational] procedure; cranial, extradural [List separately in addition to code for primary procedure]), and two other procedures; and
• 64611 (Chemodenervation of parotid and submandibular salivary glands, bilateral), and 103 other procedures.

These edits mean you won't get paid for both, so get the lowdown on how to adhere or risk giving away your profits.

For the 17.0 version, "19,822 new edit pairs have been added to the database while 9,778 have been terminated, for a net gain of 10,044 new edit pairs," according to Frank Cohen, MPA, MBB, of the Frank Cohen Group, in his Dec. 14, 2010, "NCCI Version 17.0 Change Analysis" announcement.

Welcome Into The Spotlight New NME Pairings

Nonmutually exclusive (NME) codes are services physicians often perform during the same session you cannot bill together, with one as the comprehensive or larger procedure and the other as the component. The services represented by the comprehensive code include the component code.

Rule of thumb: You can bill individual components if the physician does not perform the entire comprehensive procedure. But if the physician performs the entire comprehensive procedure, you should bill the comprehensive code instead of the individual parts or components.

NCCI 17.0 includes non-mutually exclusive edits for virtually each of the three new nasal/sinus endoscopy codes (31295-31297) when performed with several CPT codes. For instance, coding for 31295 (Nasal/sinus endoscopy, surgical; with dilation of maxillary sinus ostium [e.g., balloon dilation], transnasal or via canine fossa) is considered the

comprehensive code when performed with the following codes when a physician performs both procedures in the same session:

Sinus endoscopy--

• 31231 -- Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure)
• 31233 -- Nasal/sinus endoscopy, diagnostic with maxillary sinusoscopy (via inferior meatus or canine fossa puncture)
• 31237 -- Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement (separate procedure)
• 31238 -- Nasal/sinus endoscopy, surgical; with control of nasal hemorrhage

Vascular injection--

• 36000 -- Introduction of needle or intracatheter, vein
• 36400 -- Venipuncture, younger than age 3 years, necessitating physician's skill, not to be used for routine venipuncture; femoral or jugular vein
• 36405 -- Venipuncture, younger than age 3 years, necessitating physician's skill, not to be used for routine venipuncture; scalp vein
• 36406 -- Venipuncture, younger than age 3 years, necessitating physician's skill, not to be used for routine venipuncture; other vein
• 36410 -- Venipuncture, age 3 years or older, necessitating physician's skill (separate procedure), for diagnostic or therapeutic purposes (not to be used for routine venipuncture)
• 36420 -- Venipuncture, cutdown; younger than age 1 year
• 36425 -- Venipuncture, cutdown; age 1 or over
• 36430 -- Transfusion, blood or blood components
• 36440 -- Push transfusion, blood, 2 years or younger

Arterial--

• 36600 -- Arterial puncture, withdrawal of blood for diagnosis
• 36640 -- Arterial catheterization for prolonged infusion therapy (chemotherapy), cutdown

Transcatheter procedure--

• 37202 -- Transcatheter therapy, infusion other than for thrombolysis, any type (eg, spasmolytic, vasoconstrictive)

The same edits apply to 31295 during several specialty procedures:

• Urinary system i.e., 51701-51703
• Nervous system i.e., 62310-62319, 64400-64450
• Diagnostic radiology i.e., 76000-76001
• Cardiovascular i.e., 93000-93010, 93040-93042, 93318
• Pulmonary i.e., 94002, 94200, 94250
• Neurology and Neuromuscular procedures i.e., 95812-95822, 95829, 95955
• Medicine/Hydration i.e., 96360, 96365, 96372
• Moderate sedation i.e., 99148-99150

NCCI Edits 17.0 list the following surgical procedures -- along with 83 others -- as components of the new code 31296 (Nasal/sinus endoscopy, surgical; with dilation of frontal sinus ostium [e.g., balloon dilation]):

• 51701 -- Insertion of non-indwelling bladder catheter (e.g., straight catheterization for residual urine)
• 51702 -- Insertion of temporary indwelling bladder catheter; simple (e.g., Foley)
• 51703 -- ...complicated (e.g., altered anatomy, fractured catheter/balloon)
• 62310 -- Injection, single (not via indwelling catheter), not including neurolytic substances, with or without contrast (for either localization or epidurography), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), epidural or subarachnoid; cervical or thoracic
• 62311 -- ...lumbar, sacral (caudal)

Meanwhile, the new code for trachea and bronchi endoscopy 31634 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with balloon occlusion, with assessment of air leak, with administration of occlusive substance [e.g., fibrin glue, if performed]) is listed as a

comprehensive code for these procedures:

• 31525 -- Laryngoscopy direct, with or without tracheoscopy; diagnostic, except newborn
• 31535 -- Laryngoscopy, direct, operative, with biopsy
• 31575 -- Laryngoscopy, flexible fiberoptic; diagnostic
• 31622 -- Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; diagnostic, with cell washing, when performed (separate procedure)

In addition, new destruction code 64611 (Chemodenervation of parotid and submandibular salivary glands, bilateral) also is listed as the comprehensive code within nonmutually exclusive edit for several procedures including:

• 00100 -- Anesthesia for procedures on salivary glands, including biopsy
• 36410 -- Venipuncture, age 3 years or older, necessitating physician's skill (separate procedure), for diagnostic or therapeutic purposes (not to be used for routine venipuncture)
• 95937 -- Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method
• 99148 -- Moderate sedation services (other than those services described by codes 00100-01999), provided by a physician other than the health care professional performing the diagnostic or therapeutic service that the sedation supports; younger than 5 years of age, first 30 minutes intra-service time

NCCI Edits 17.0 cites the reason "Anesthesia service included in surgical procedure" for the NME pairing between 64611 and 00100. On the other hand, "misuse of column two code with column one code" appears as the reason for the 64611- 99148 pairing. "CPT 64611 includes moderate sedation andit therefore cannot be billed separately," explains Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J.

Hint: Some edit pairs carry a modifier indicator of "1," meaning you can sometimes bypass the edit by filing your claim with an appropriate modifier (e.g., 95801, Sleep study, unattended, simultaneous recording; minimum of heart rate, oxygen saturation, and respiratory analysis [e.g., by airflow or peripheral arterial tone], and 94660, Continuous positive airway pressure ventilation [CPAP], initiation and management). Don't forget that the supporting documentation must have support for the modifier use which overrides the NCCI edits whenever they are used.

Old Excision Codes Get Subjected To Edits

Head excision codes 21011-21016 describe more specific scenarios based on size for when head tumor are excised or resected:

• 21011 -- Excision, tumor, soft tissue of face or scalp, subcutaneous; less than 2 cm
• 21012 -- Excision, tumor, soft tissue of face or scalp, subcutaneous; 2 cm or greater
• 21013 -- Excision, tumor, soft tissue of face and scalp, subfascial (eg, subgaleal, intramuscular); less than 2 cm
• 21014 -- Excision, tumor, soft tissue of face and scalp, subfascial (eg, subgaleal, intramuscular); 2 cm or greater
• 21015 -- Radical resection of tumor (eg, malignant neoplasm), soft tissue of face or scalp; less than 2 cm
• 21016 -- Radical resection of tumor (eg, malignant neoplasm), soft tissue of face or scalp; 2 cm or greater

NCCI Edits 17.0 defines a specific component code for each of these new codes: 97597 (Debridement [e.g., high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps], open wound, [e.g., fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm], including topical application[s], wound assessment, use of a whirlpool, when performed and instruction[s] for ongoing care, per session, total wound[s] surface area; first 20 sq cm or less). Neck excision codes 21552-21558 undergo similar edits with the same component code (97597). "This is because NCCI considers the lesion excision or resection complete and wound care on the same day to be a component of the lesion excision or resection. Code 97597 represents wound care," says Cobuzzi. "But since the modifier in the edit is a '1', a modifier may be used, such as a 59 modifier for a separate site, if wound care is performed at a separate site from the lesion excision or resection," she adds.

Two other CPT veteran excision codes 41114 (Excision of lesion of tongue with closure; with local tongue flap) and 42550 (Injection procedure for sialography) are listed as comprehensive codes for 41112 (Excision of lesion of tongue with closure; anterior two-thirds), 41113 (Excision of lesion of tongue with closure; posterior one-third), and 77001 (Fluoroscopic guidance for central venous access device placement, replacement [catheter only or complete], or removal [includes fluoroscopic guidance for vascular access and catheter manipulation, any necessary contrast injections through access site or catheter with related venography radiologic supervision and interpretation, and radiographic documentation of final catheter position] [List separately in addition to code for primary procedure]), respectively.

E/M Codes Dig Up Own NME Edits

Make sure you don't leave out nonmutually exclusive pairings for E/M service codes including between three debuting E/Ms for hospital observation care (99224-99226) and other procedures.

For instance, 99224 (Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: Problem focused interval history; Problem focused examination; Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem[s] and the patient's and/or family's needs. Usually, the patient is stable, recovering, or improving. Physicians typically spend 15 minutes at the bedside and on the patient's hospital floor or unit.) gets paired with other E/M codes such as:

• 99201- 99217 (Office or other outpatient services)
• 99281- 99285 (Emergency department services)
• 99307- 99310 (Subsequent nursing facility care)
• 99318 (Evaluation and management of a patient involving an annual nursing facility assessment, which requires these 3 key components: A detailed interval history; A comprehensive examination; and Medical decision making that is of low to moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem[s] and the patient's and/or family's needs. Usually, the patient is stable, recovering, or improving. Physicians typically spend 30 minutes at the bedside and on the patient's facility floor or unit.)
• 99324- 99328 (Domiciliary, rest home [e.g., boarding home], or custodial care services)
• 99334- 99337 (...established patient)
• 99341- 99350 (Home services)