Otolaryngology Coding Alert

The Fee Schedule 's preamble discusses a new HCPCS level-two code for physician cerumen removal: G0268 (Removal of impacted cerumen [one or both ears] by physician on same date of service as audiologic function testing). Medicare previously assumed that an audiologist always performed cerumen removal and considered the procedure integral to an audio, says 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. "CMS created the new code to reimburse doctors for complicated impacted cerumen removal that requires a physician's skill."

Consider the code the cerumen-removal equivalent of 36410* (Venipuncture, child over age 3 years or adult, necessitating physician's skill [separate procedure], for diagnostic or therapeutic purposes. Not to be used for routine venipuncture). You would report 36410 only when the procedure requires a physician's skill. Similarly, you should report G0268 only when cerumen removal is too complicated for the audiologist to perform, meaning it is truly impacted, so the otolaryngologist must perform the procedure, Cobuzzi explains. For a simple wash performed to get a valid audiology test, you should not use G0268.

For example, an established patient complains of coughing, sneezing, fatigue and achiness. The otolaryngologist takes a history and examination and uses medical decision-making. He diagnoses acute sinusitis, removes impacted cerumen from the patient's ear canal and sends the patient to the audiologist for pure tone air audiometry.

You should report all three services and procedures. For the office visit, report 99211-99215 (Office or other outpatient visit for an established patient) appended with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to indicate a significant, separately identifiable service. For the cerumen removal, assign G0268. For the audiometry, use 92552 linked to the diagnosis for the hearing-related condition, such as unspecified sensorineural hearing loss (389.10). Link the diagnosis for acute sinusitis (461.9, Acute sinusitis, unspecified) to the office visit (9921x) and the diagnosis for impacted cerumen (380.4) to cerumen removal (G0268).

Insurers should pay for all three services and procedures, Cobuzzi says. "But, we're not sure if carriers will follow these guidelines."

CMS awarded G0268 the same physician work RVUs, practice expense inputs and malpractice RVUs as it assigned to 69210 (Removal impacted cerumen ...). "The inclusion will help as long as Medicare and the Part B carriers recognize the code like they are stating they will," says Edie Scully, office administrator for Baton Rouge Ear, Nose and Throat in Louisiana.

Improper routine use of G0268 will raise a red flag. To avoid accusations of abuse, create a practice policy that defines when the coder would use G0268 to ensure that it is not billed routinely, says Cheryl Odquist, CPC, a reimbursement and compliance consultant, president of Codeology in San Diego, and American Academy of Professional Coders (AAPC) San Diego chapter president. "Place the policy within the Practice Compliance Plan under Coding," she instructs. In addition, practices may want to use an advance beneficiary notice to inform patients that carriers may not cover cerumen removal as a nonroutine service.

New FEES/FEEST Codes Replace G Codes

To report evaluation and swallowing studies in 2002, otolaryngologists had to use 92525 (Evaluation of swallowing and oral function for feeding) or one of two HCPCS level-two G codes, G0193 (Endoscopic study of swallowing function [also fiberoptic endoscopic evaluation of swallowing] [FEES]) and G0194 (Sensory testing during endoscopic study of swallowing [add-on code] referred to as fiberoptic endoscopic evaluation of swallowing with sensory testing [FEEST]), depending on the payer. When CPT 2003 introduced new FEES and FEEST codes, experts were unsure whether Medicare would accept these new codes.

CMS announced that Medicare will accept these new codes and directs coders to use the new CPT codes instead of the level-two codes. You should now report 92610 (Evaluation of oral and pharyngeal swallowing function) instead of G0195 (Clinical evaluation of swallowing function [not involving interpretation of dynamic radiological studies or endoscopic study of swallowing]). For services you previously billed as G0196 (Evaluation of swallowing involving swallowing of radio-opaque materials), use 92611 (Motion fluoro-scopic evaluation of swallowing function by cine or video recording). Assign 92612 (Flexible fiberoptic endoscopic evaluation of swallowing by cine or video recording) instead of G0193, and 92614 (Flexible fiberoptic endoscopic evaluation, laryngeal sensory testing by cine or video recording) for G0194.

Although Medicare recognizes the new codes, it will not pay any physician work RVUs for 92610 and 92611. When Medicare does not assign any physician work RVUs to a code, they assume a technician is performing the procedure. CMS granted 1.27 work RVUs for 92612 and 92614. Code 92616 (Flexible fiberoptic endoscopic evaluation of swallowing and laryngeal sensory testing by cine or video recording) received the most RVUs (1.88) of any of the new evaluation and swallowing codes.

CMS does not grant any physician work RVUs to the codes for interpretation and report only (92613, 92615 and 92617 [... physician interpretation and report only]). CMS considers the physician interpretation and report bundled into an E/M service, according to the final rule. Because the agency considers the test's interpretation an integral part of the testing, it will not grant separate RVUs for the interpretation only.

When the doctor performs an E/M service that leads to ordering the test, he or she should report the E/M service only. But if the physician merely supervises another professional who performs and reviews the initial fiberoptic endoscopic evaluation, the ordering doctor should not bill for the test, CMS states. If a nonphysician professional performs the study, he or she should also provide the interpretation of the findings, CMS concludes.

Medicare made two of the new evaluation and therapy codes 92605 (Evaluation for prescription of non-speech-generating augmentative and alternative communication device) and 92606 (Therapeutic service[s] for the use of non-speech-generating device, including programming and modification) bundled codes (identified with a "B" on the fee schedule). The fee schedule bundles the services into the old evaluation and treatment codes 92506 (Evaluation of speech, language, voice, communication, auditory processing, and/or aural rehabilitation status) and 92507 Treatment of speech, language, voice, communication, and/or auditory processing disorder [includes aural rehabilitation]; individual). Medicare will not grant any RVUs or payment for the non-speech-generating device codes (92605, 92606).

"92605 and 92606 typically do not involve the same type of highly specialized equipment as the codes for speech-generating devices," CMS states. Codes 92506 and 92507 contain the work associated with 92605 and 92606, and therefore the agency makes 92605 and 92606 bundled  services. You should report the codes for speech-generating devices rather than the non-speech-generating codes.

Medicare will no longer cover aural rehabilitation code 92510 (Aural rehabilitation following cochlear implant [includes evaluation of aural rehabilitation status and hearing, therapeutic services] with or without speech processor programming) because new CPT codes 92601 (Diagnostic analysis of cochlear implant, patient under 7 years of age; with programming), 92602 (... subsequent reprogramming), 92603 (Diagnostic analysis of cochlear implant, age 7 years or older; with programming) and 92604 (... subsequent reprogramming) overlap with 92510. For the remaining services that do not involve reprogramming the cochlear implant, Medicare directs coders to report 92507 as the note in the CPT manual under 92602 directs.

Medicare made this decision based on erroneous information. The AMA CPT Errata corrected the note following 92602. The instruction should state: "For aural rehabilitation services following cochlear implant, including evaluation of rehabilitation status, use 92510." Do not report 92507 for aural rehabilitation following cochlear implant. For claims involving 92510, you should follow the new CPT directive and point out the error to Medicare. The preamble also instructs which CPTcodes replace several temporary G codes. Physicians and coders should follow the chart on page 19 to report the appropriate 2003 CPTcode rather than the deleted G code.