Otolaryngology Coding Alert

Although neither code specifies placement and removal, both codes imply placement and removal. The only CPT code that explicitly refers to tube removal is 69424 ventilating tube removal when originally inserted by another physician"" (emphasis added). In 69424's definition" CPT implies that when the same physician who placed the tubes removes them the tube placement (69433 or 69436) includes the removal.

Despite low reimbursement for tube placement "subsequent removal is built into the relative value units and therefore should not be billed " says Beth Thomsen CPC ENT department billing coordinator for Associated Physicians of Medical College of Ohio in Toledo. Even if a physician removes the tubes years after he placed them 69424 should not be billed.

"This applies not only to the physician who placed the tubes and the other physicians in the same group practice but also to the on-call physician who when treating another's patients is required to bill those patients as established " Thomsen explains.

After 69436's 10-day global period expires you should report follow-up visits with the appropriate established patient office visit code (99211-99215). To understand how to code follow-up visits let's follow a hypothetical tubes patient.

Suppose an otolaryngologist treats a 3-year-old child who has chronic otitis media (382.9). The physician decides to place ventilating tubes in the girl's ears to reduce the recurrent infections. Because of the child's age the doctor performs tympanostomy under general anesthesia. For the first ear the physician reports 69436. For the second ear she assigns 69436-50 (Bilateral procedure).

If the child returns in four to six months for a checkup use 99211-99215 to report the visit. Use the original otitis media diagnosis to explain the E/M visits. Code 382.9 is still appropriate because it explains why the physician is seeing the patient and why she has tubes in her ears.

If the otolaryngologist inspects the tubes and the tympanic membrane using the binocular microscope during one of these visits with the same 3-year-old assign either 92504 (Binocular microscopy [separate diagnostic procedure]) or 99211-99215 (Established patient office visit). That's because the special otorhinolaryngologic services codes (92502-92526) encompass the E/M CPT explains in its introduction to this code series. Because 99212-99215 (.45-1.77 work relative value units [RVUs]) pay more than 92504 (.18 work RVUs) with proper documentation you may choose to report the appropriate office visit rather than the procedure.

Suppose nine months pass without incident. The otolaryngologist spends 12 minutes discussing with the mother removing the tubes. Select an E/M level based on time e.g. 99213 Office or other outpatient visit. When time determines the E/M visit's level the doctor must document the visit's total time time spent counseling and the reason for the counseling

The next week the otolaryngologist removes the tubes under general anesthesia. Because the doctor has already assessed the child's condition she does not fully examine the child. Instead she checks the child's ears when she removes the tubes. Report 92502 (Otolaryngologic examination under general anesthesia).

Some coders recommend appending modifier -52 (Reduced services) to 92502. The services cannot support the full code because the doctor does not look at the throat or the larynx argues Andrew Borden CPC CCS-P CMA reimbursement manager for the department of otolaryngology at the Medical College of Wisconsin in Milwaukee.

However 92502 does not specify that the exam must include the ear nose and throat. Otolaryngologists usually proceed to an exam under general anesthesia after conducting an initial assessment which identifies the targeted areas. Because no medical necessity would exist to examine all three areas again it seems logical that CPT would not intend for 92502 to require a complete evaluation making modifier -52 unnecessary.

During the examination the doctor discovers a small perforation in the tympanic membrane. She either prepares or patches the drum for the closure. For the repair on the left ear assign 69610 (Tympanic membrane repair with or without site preparation or perforation for closure with or without patch). Do not also code the exam because the Correct Coding Initiative (CCI) bundles 92502 with 69610.

However the bundle applies to the same ear only. Consider the same scenario if the physician also extracts the tube from the right ear. Report 69610 92502-52-59. Here's the breakdown. For the repair use 69610. For the tube removal bill 92502. Because 92502 is a bilateral code and you are billing for one side only append modifier -52 (Reduced services). In addition you need to indicate that the procedure occurred on a separate side or location from the repair. Therefore also use modifier -59 (Distinct procedural service).

Suppose the child's family had relocated and a different doctor removed the tubes and performed a simple repair. Because these codes are unilateral the most extensive procedure performed on each ear may be reported. The new otolaryngologist should bill the left ear repair 69610 and the tube removal of the right ear 69424.

To indicate that the procedures were performed on separate sites append modifier -59 on the lower-level procedure (69424) and modifiers -LT (Left side) and -RT (Right side) for clarification. The claim should read 69610-LT 69424-59-RT.

When a tube removal and repair on the same ear are performed the CCI bundles the removal as incidental to the repair. "You can't perform a tympanic repair without removing the tubes " Borden explains.

Some coders report receiving reimbursement for billing a foreign-body removal when the otolaryngologist removed a ventilating tube. However PE tubes do not constitute a foreign body. "A foreign body ends up in an organ system by accident not on purpose " Borden explains. "A tube is designed to go there and is placed intentionally." Reporting a tube removal with 69200 (Removal foreign body from external auditory canal; without general anesthesia) is inappropriate and would not withstand an audit.