Otolaryngology Coding Alert

Correct Coding Initiative version 8.1 (CCI 8.1) (effective April 1-June 30, 2002) includes many new otolaryngology code edits, the most important of which are those bundling repair of nasal vestibular stenosis (RNVS) with rhinoplasty and septoplasty. Edits involving RNVS set new payment guidelines, mainly because 30465 (Repair of nasal vestibular stenosis [e.g., spreader grafting, lateral nasal wall reconstruction]) was introduced only recently (CPT 2001).

Although cerumen removal was already bundled with many audiological tests, CCI 8.1 bundles it with several more tests. CCI and many payers (including Part B carriers) bundle these procedures on grounds that the ears must be free of obstruction before tests can be performed. The edits represent Medicare's official ruling on the matter and end any speculation regarding whether cerumen removal may be billed with specific tests mentioned in the edits.

Other edits in CCI 8.1, including those regarding planned tracheostomy (31600) and otolaryngologic examination under general anesthesia (92502), also bring the CCI in line with current coding practice.

CCI 8.1 bundles RNVS code 30465 with rhinoplasty codes 30400, 30410, 30420, 30435 and 30450 and septoplasty code 30520.

Like most otolaryngology procedures, 30465 now includes as component codes 92502 and +69990 (Microsurgical techniques, requiring use of operating microscope [list separately in addition to code for primary procedure]).

Code 30465 is considered mutually exclusive with rhinoplasty codes 30460 and 30462, as well as 30620 (Septal or other intranasal dermatoplasty [does not include obtaining graft]).

Bundling 30465 as a component of rhinoplasty and septoplasty codes creates a billing challenge, particularly with regard to septoplasty. When procedures bearing comprehensive and component codes are performed during the same session, only the comprehensive code is reported. There is little effect on reimbursement when one of the rhinoplasty codes is reported as the comprehensive code. These codes reimburse at rates close to, equal to or higher than the 22.19 relative value units (RVUs) set for 30465. It is an issue, however, when the septoplasty code is reported as the comprehensive code because the rate set for 30520 (12.04 RVUs) is less than that set for 30465. In this case, the effect on reimbursement is marked enough that you should contact your Part B carrier to express your concerns and question whether billing 30465 in place of 30520 is acceptable.

"This may be an error that the CCI will correct in a later version," says Elaine Elliott, CPC, an otolaryn-gology coding and reimbursement specialist in Jensen Beach, Fla. "I think they are bundling them because both rhinoplasty and septoplasty codes say with or without cartilage graft, and cartilage graft is also involved in RNVS. But RNVS is an entirely separate and much more delicate procedure than septoplasty because it involves work where the upper and lateral cartilages come together with much softer cartilage."

Lee Eisenberg, MD, an otolaryngologist in private practice in Englewood, N.J., and a member of CPT's Editorial Panel and Executive Committee, concurs. "It's hard to believe that Medicare intends for the otolaryn-gologist to get paid more for RNVS performed alone than when it is done in conjunction with septoplasty," he says, noting that a patient can have a perfectly straight septum and still have nasal valve stenosis at the upper lateral border.

If the patient has a deviated septum and the otolaryn-gologist works on the upper lateral cartilage as part of the repair, the edit suggests that it may not be reported separately. If the patient has a deviated septum and there is a separate problem with the upper cartilage, however, Elliott recommends billing both procedures with modifier -59 (Distinct procedural service) appended to 30520 to override the edit.

Past CCI versions bundled many audiological tests (i.e., 92557) with cerumen removal (69210) even though CPT says nothing about bundling these procedures.

CCI Chapter One, Section C1 (last revised in CCI 7.3) explains that in the case of cerumen impaction prior to myringotomy, cerumen removal is included because "the cerumen impaction is precluding access to the tympanic membrane and its removal is necessary for the successful completion of the myringotomy." Using this rationale, Medicare has determined that wax must be removed from a patient's ear before a proper hearing test can be conducted.

CCI 8.1 bundles seven more audiological test codes (92552, 92553, 92555, 92556, 92567, 92568 and 92586) with 69210.

The new edits bear a "0" indicator, which means you cannot use modifier -59 to bypass them even if criteria for using the modifier have been met.

Although CCI 8.1 edits of interest to otolaryngologists are too numerous to list here, some of the more significant edits are described below: