Otolaryngology Coding Alert

Understand the ENT's role and the appropriate CPT^® and modifier designations.

Occasionally, ENTs will be called upon to perform surgical approaches to neurosurgical procedures, among other specialties. While these scenarios may not be commonplace, you've got to know what modifiers and procedural codes to utilize when billing for the ENT's portion of the surgery. When it comes to neurosurgical operations, otolaryngologists are often called upon to team with neurosurgeons for transnasal and transsphenoidal removals of pituitary tumors.

As long as the neurosurgeon opts for a transnasal or transsphenoidal neuroendoscopic approach, the neurosurgeon will typically require the ENT to perform an approach of his or her own. This approach may include a sphenoidotomy, septoplasty, and even a concha bullosa resection, when necessary.

If you find yourself in the midst of coding one of these complicated scenarios, you've got to have a firm understanding of all the necessary steps required to accurately code on your ENT's behalf. Check out these helpful tips and expert advice for all you need to know about co-billing for a neuroendoscopic pituitary removal procedure.

Distinguish ENT, Neurosurgeon's Respective Roles

When determining the correct procedural code for an excision of a pituitary tumor, your main focus should be on the surgeon's approach to the excision. Traditional pituitary excision approaches typically follow by one of three methods:

• Open craniotomy;
• Transnasal/transseptal, microscopic approach; or
• Transnasal/transsphenoidal, neuroendoscopic approach.

In cases where the neurosurgeon opts for the third option (transnasal/transsphenoidal), the neurosurgeon will call upon the assistance of an otolaryngologist to perform the underlying approach. As a whole, you will bill this procedure out under code 62165 (Neuroendoscopy, intracranial; with excision of pituitary tumor, transnasal or trans-sphenoidal approach).

For most coders attempting to bill the ENT's portion of this procedure, the initial hang-up comes during the process of code allocation. An obedient coder may think that he or she is making all the right moves by first checking for any Correct Coding Initiative (CCI) edits in place between code 62165 and the various approach maneuvers the ENT may have performed. However, as you will see, CCI edits don't tell the whole story when it comes to co-surgeons performing a routine 62165.

Pinpoint Extent of ENT's Approach

Consider the following possible approaches an otolaryngologist might perform during a 62165:

• 30520 - Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft
• 31287 - Nasal/sinus endoscopy, surgical, with sphenoidotomy
• 31240 - Nasal/sinus endoscopy, surgical; with concha bullosa resection

Now, take a look at the CCI edits between these codes and 62165. As you can see, you should not bill 30520 alongside 62165 under any circumstances, so excluding this option is easy. However, the other two codes, 31287 and 31240, do not have any CCI edits in place alongside 62165.

While some coders may assume that the otolaryngologist should bill out individually for approach codes such as a septoplasty and sphenoidotomy, these procedures are actually considered an included component in code 62165.

"Code 62165 includes the entirety of both the ENT's portion of the procedure- endoscopic approach- and the neurosurgeon's portion for the excision of the pituitary tumor," says Jennifer M. Connell, CPC, COC, CENTC, CPCO, CPMA, CPPM, CPC-P, CPB, CPC-I, CEMA, owner of E2E Health Solutions in Victoria, Texas. "Both the ENT and neurosurgeon would bill 62165 with modifier 62 [Two Surgeons] and should expect around 62.5 percent of the contract rate - some payers are a little higher," Connell explains.

Consider Time, Work Before Coding Concha Bullosa Resection

Additionally, you should be wary of including procedure code 31240 (Nasal/sinus endoscopy, surgical; with concha bullosa resection) if the otolaryngologist performs a concha bullosa removal as part of the initial approach. "In order to bill separately, it should be a significant procedure that takes a measurable amount of time. It is not expected that an ENT would bill for endoscopic removal of a small concha bullosa that took 2 minutes," says Connell.

So, instead of billing out separately for the ENT's approach, both the ENT and the neurosurgeon will actually be billing out for 62165, alone. Both the ENT and the neurosurgeon will apply modifier 62 to their respective codes and will be paid accordingly.