Otolaryngology Coding Alert

Otolaryngologists and their coders will want to pay close attention to Correct Coding Manual version 7.3 (CCM 7.3), the latest version of the manual that compiles all changes to the Correct Coding Initiative (CCI), as it includes revisions to long-standing coding principles. Most of the changes that affect otolaryngologists appear in Chapter One of the CCI, entitled "General Correct Coding Policies."
 
Chapter One/Section B, for instance, clearly states that individual services are included with more "comprehensive" procedures because:
 
1. The service represents the standard of care in accomplishing the overall procedure.
 
2. The service is necessary to successfully accomplish the comprehensive procedure; failure to perform the service may compromise the success of the procedure.
 
3. The service does not represent a separately identifiable procedure unrelated to the comprehensive procedure planned.

Section C1 now refers to "removal of a cerumen impaction prior to myringotomy" as an included service, noting that removal of impacted cerumen is included in the myringotomy because "the cerumen impaction is precluding access to the tympanic membrane and its removal is necessary for the successful completion of the myringotomy." Similarly, "a cursory evaluation of the upper airway as part of a bronchoscopic procedure would not be separately reported as a laryngoscopy, sinus endoscopy, etc."
 
"Many experienced otolaryngology coders already apply these principles," notes Barbara Cobuzzi, MBA, CPC, CPC-H, an otolaryngology coding and reimbursement specialist and President of Cash Flow Solutions, a medical billing firm in Lakewood, N.J. "Having it there in writing can only help coders deal with their carriers and with their otolaryngologists, who may believe the procedures in question should be billed separately."
 
Chapter One includes changes that may affect coding and billing practices more directly, specifically relating to biopsies and other endoscopic procedures, procedures involving multiple lesions and services with XXX global days and E/M services performed on the same day.
 
Cobuzzi recommends that otolaryngology practices become familiar with all CCI policies. "These guidelines, especially those in Chapter One, have a lot of important information for otolaryngology practices," she says. "They are easy to reference and cover many of the issues that physicians and coders find most confusing."

Modifier -25. A short-lived policy introduced in 2000 bundled E/M services with codes with XXX global days. Physicians complained about the numerous CCI edits that the policy generated, prompting CMS to suspend it after only a few months. The same policy, which requires that modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) be appended to significant, separate E/M services, has been revived. CMS has reformulated the policy via a back door, without reintroducing the edits themselves, Cobuzzi says. Chapter One states: "Many of these 'XXX' procedures are performed by physicians and have inherent pre-procedure, intra-procedure and post-procedure work usually performed each time the procedure is completed. This work should never be reported with a separate E/M code With most 'XXX' procedures, the physician may, however, perform a significant and separately identifiable E/M service on the same day of service which may be reported by appending the -25 modifier to the E/M code." 

This guideline may be significant for some otolaryngology practices that perform audiology and allergy tests. Practices that already only billed for significant and separate E/M services will see little change, even if their Part B carrier enforces the directive in the CCI, notes Randa Blackwell, financial specialist, Division of Otolaryngology, Department of Surgery, University of Maryland in Baltimore. "If the carrier requires modifier -25 on diagnostic tests, the only difference for our office will be listing modifier -25. Our staff are already trained to bill for E/M only if there is a significant, separately identifiable service provided," she says.
 
In addition to the requirement that modifier -25 be appended to significant, separately identifiable E/M services, the policy states that "a physician should never report a separate E/M code with [procedures with XXX global days] for the supervision of others performing the procedure or for the interpretation of the procedure." If the otolaryngologist receives test results from an audiologist and interprets those results, Blackwell says, no separate E/M should be reported, as the interpretation is included in the appropriate audiology test code itself. If the otolaryngologist takes a history, examines the patient and makes medical decisions in addition to ordering the audiology, however, a separate E/M service may be billed (with modifier -25 appended). Furthermore, the interpretation of the test(s) may boost the level of decision-making, which may influence the overall E/M level.
 
Modifier -58. If a diagnostic endoscopy prompts the decision to perform an open surgical procedure on the same day, the revised instructions state that modifier -58 (staged or related procedure or service by the same physician during the postoperative period), rather than modifier -59 (distinct procedural service), should be appended to the more extensive surgical procedure.
 
Modifier -59. CCM 7.3 instructs coders on the appropriate use of modifier -59: "When certain services are reported together, there may be a perception of 'unbundling,' when, in fact, the services were performed under circumstances which did not involve this practice at all The -59 modifier indicates that the procedure represents a distinct service from others reported on the same day of service. This may represent a different session, different surgery, different site, different lesion, different injury or area of injury (in extensive injuries)."
 
Note: If another modifier describes a situation more specifically, it should be used in place of modifier -59.
 
For example, a patient requiring the surgical excision of three facial lesions should be billed to Medicare carriers (and most private payers) using 11440 (excision, other benign lesion [unless listed elsewhere], face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.5 cm or less), 11440-59 and 11440-59. The otolaryngologist uses modifier -59 to inform the carrier that the excisions were for different lesions at different sites on the face.
 
Note: If the carrier requires units for this service, rather than multiple listings, 11440 should be billed only once with a "3" in the units box of the CMS claim form.
 
The patient's medical record should clearly state the location of the lesions. If the claim is filed electronically, a phrase such as "three individual lesions removed" should be included as free text to support the modifier -59 claim.

Chapter One/Section C4 of the CCI includes significant new instructions on billing for multiple biopsies:

 

When a single lesion is biopsied multiple times, only one biopsy removal service should be reported. Sometimes a biopsy does not yield a definitive diagnosis, and another biopsy must be taken. The otolaryngologist cannot, however, bill for each biopsy.

 

When multiple distinct lesions are non-endoscopically biopsied, a biopsy removal service may be reported for each lesion separately with modifier -59, indicating a different service was performed or a different site was biopsied. An otolaryngologist taking biopsies from two separate sites on the floor of the mouth, for example, may report the biopsies separately (as long as the medical record indicates the distinct nature of this service by identifying the precise location of each biopsy site) using 41108 (biopsy of floor of mouth) and 41108-59.
 
Note: Modifier -59 should not be used for multiple biopsies of the skin, which should be reported using 11100 (biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed [separate procedure]; single lesion) and 11101 ( each separate/additional lesion [list separately in addition to code for primary procedure]).

 

Multiple endoscopic biopsies of multiple lesions are reported with one unit of service, regardless of how many biopsies are taken. "This is a basic rule of endoscopy," notes Cobuzzi. "Once the scope is down, it doesn't matter how many other biopsies are performed." If another service is performed, both services may be billed, with modifier -59 appended to the lesser-valued procedure.

 

If the decision to perform a more comprehensive open procedure is based on the biopsy result, the biopsy is considered diagnostic and the service may be reported separately. If the otolaryngologist obtains a frozen section of a lymph node that returns positive within 30 minutes, for example, the otolaryngologist may perform a neck dissection. Both the lymph node biopsy and the neck dissection may billed, with modifier -58 appended to the comprehensive procedure.

Like diagnostic biopsies, other diagnostic endoscopic services may be reported separately if the decision for surgery was made on the basis of the endoscopy (but only if the surgery is open). Chapter One/Section 8 of the CCI states that modifier -58 "may be used to indicate that the diagnostic endoscopy and the open surgical service are staged or planned procedures." As a result, Chapter One/Section H3 notes that "from the National Correct Coding Initiative perspective, this action would result in the allowance and reporting of both services as separate and distinct," as long as "scout endoscopy" was not performed.
 
Note: CCI states that scout endoscopy "represents a part of the assessment of the surgical field to establish anatomical landmarks, extent of disease, etc."
 
If the endoscopic service was performed "to establish the location of a lesion, confirm the presence of a lesion, establish anatomic landmarks or define the extent of a lesion" and did not result in the decision for open surgery, "the endoscopic service should not be reported separately, as it is a medically necessary part of the overall surgical service." If endoscopic surgery such as 31577 (laryngoscopy, flexible fiberoptic; with removal of foreign body) is performed after 31575 (laryngoscopy, flexible fiberoptic; diagnostic), only the surgical procedure should be billed.

Chapter Six/Section B8 of the CCI reiterates that control of bleeding at the time of a procedure is an included service and should not be billed separately, regardless of whether the procedure is endoscopic or open. If an endoscopic procedure is performed and a second endoscopic procedure must be performed later the same day to control bleeding, however, the second procedure may be reported separately with modifier -59.
 
Note: Remember that the guidelines in the CCI narrative do not necessarily apply to non-Medicare carriers.