Otolaryngology Coding Alert

CPT 2001 includes several important changes for otolaryngologists, including new codes for repair of nasal vestibular stenosis, osteotomy with genioglossus advancement and implantation of bone-attached cochlear devices. Because these procedures were previously billed using either inaccurate or unlisted codes, the new codes are being welcomed by otolaryngologists and their coders.

Coinciding with the release of CPT 2001, the Health Care Financing Administration (HCFA) published its final rule (which contains the 2001 fee schedule) in the Nov. 1, 2000, Federal Register. In addition to boosting the relative value unit (RVU) conversion rate from $36.6137 per RVU in 2000 to $38.2581 per RVU in 2001 (a 4.4 percent increase), the fee schedule also includes coverage and reimbursement information about the new CPT codes. The following five procedures relate directly to otolaryngologic practice.

New Code Review

1. Repair of nasal vestibular stenosis. Code 30465 (repair of nasal vestibular stenosis [e.g., spreader grafting, lateral nasal wall reconstruction]; 21.58 RVUs) may be the most welcome CPT addition. The procedure is performed on patients who have developed nasal stenosis (i.e., scarring or contracture, causing an internal narrowing of the nasal valve), often as a result of prior surgery. This affects the patients breathing, so the otolaryngologist must revise the tip of the nose.

Until now, this procedure has been coded using rhinoplasty codes, but carriers often categorize such procedures as cosmetic, even though the procedure is performed to improve the patients breathing, says Lee Eisenberg, MD, an otolaryngologist in Englewood, N.J., and a member of CPTs editorial panel and executive committee.

This is a great code that has been needed for a long time, Eisenberg says. Everyone used to look at this kind of work as cosmetic, but with the new code, it will be correctly seen as a functional repair.

CPT notes, however, that 30465 does not include obtaining graft for the procedure and instructs otolaryngologists to see codes 20900-20926 and 21210 (as appropriate). In addition, the code is used to report a bilateral procedure. If the procedure is performed on one side only, modifier -52 (reduced services) should be appended.

2. Osteotomy with genioglossus advancement. This new code (21199, osteotomy, mandible, segmental; with genioglossus advancement; 27.53 RVUs) relates specifically to a procedure performed on obstructive sleep apnea patients, says Randa Blackwell, a coding and reimbursement specialist with the department of otolaryngology at the University of Maryland in Baltimore.

In this procedure which Blackwell describes as the standard of care for patients who have already had uvulopalatopharyngoplasty that did not eliminate the problem the chin is moved and the tongue is advanced to lessen or eliminate airway obstruction.

This code will make otolaryngologists happy, Blackwell says, noting that carriers, including Medicare, do not cover the procedure. This may change now that the procedure is described by a specific CPT code.

Now the procedure is coded using 21299 (unlisted craniofacial and maxillofacial procedure), although some otolaryngologists may have incorrectly used 21121 (genioplasty; sliding osteotomy, single piece), which is a dental procedure for overbite, Blackwell says.

3. Naso- or Oro-gastric Intubation. Despite the introduction of a new CPT code (43752, naso- or oro-gastric tube placement, necessitating physicians skill; 0 RVUs), many carriers are unlikely to pay for naso- or oro-gastric intubation by a surgeon. This service is typically performed by a nurse, but sometimes the patients circumstances make the intubation more difficult and a physician has to be called in. That is why 43752 includes the phrase necessitating physicians skill.

CPT 2001 also instructs physicians to use 76000 (fluoroscopy [separate procedure], up to one hour physician time, other than 71023 or 71034 [e.g., cardiac fluoroscopy]) if fluoroscopy is used to guide the tube and ensure it doesnt enter the patients lungs.

But, CPT also states that 43752 is included in critical care (99291-99292) and should not be billed separately in those situations.

Because intubation is also considered an integral part of most procedures, 43752 should be coded only when no other procedure is performed (i.e., at bedside). Even so, most carriers will likely not pay for the service. In its 2001 fee schedule, HCFA does not associate any work RVUs with 43752 and says it deferred making a recommendation on the practice expense (RVUs). The final rule states we believe this service is bundled into evaluation and management services. In the fee schedule, 43752 has a B status indicator, meaning HCFA considers it a bundled code. Payment for such services is always bundled into payment for another service.

Note: If the carrier does not cover 43752 and all the surgeon did was intubate the patient, an appropriate (low) level evaluation and management (E/M) code should be used.

4. Bone-attached Cochlear Implants. Otolaryngologists who specialize in otology will benefit from the introduction of four new codes that describe implantation and replacement of osseointegrated implants that are percutaneously connected to cochlear stimulators. The four new codes are:

69714 implantation, osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; without mastoidectomy (23.68 RVUs);

69715 implantation, osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; with mastoidectomy (29.99 RVUs);

69717 replacement (including removal of existing device), osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; without mastoidectomy (24.39 RVUs); and

69718 replacement (including removal of existing device), osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; with mastoidectomy (30.35 RVUs).

These procedures, which have been coded using unlisted code 69799 (unlisted procedure, middle ear), are performed on patients with neurosensory hearing loss, and involve attaching a receiver to the temporal bone that is connected to an external stimulator and an electrode placed in the cochlea. It differs from a traditional cochlear implant (69930, cochlear device implantation, with or without mastoidectomy) in that the receiver is anchored to the patients bone.

Bone-anchored hearing aids are not new, but until now the only installation and repair codes available (69710, implantation or replacement of electromagnetic bone conduction hearing device in temporal bone [replacement procedure includes removal of old device] and 69711 (removal or repair of electromagnetic bone conduction hearing device in temporal bone) were for conduction hearing devices only.

5. Microsurgical Grafting for Facial Nerve Paralysis. Code 15842 (graft for facial nerve paralysis; free muscle flap by microsurgical technique) has been revised. A notation below the code descriptor now says: Do not report 69990 (use of operating microscope) in addition to 15842.