Otolaryngology Coding Alert

Plus, know how to properly bill AERA with 69436.

Prior to the development of the Acclarent AERA Eustachian Tube Dilation (ETD) System, treatment for persistent eustachian tube dilation was limited to medication and complicated surgical procedures. With AERA, surgeons can safely dilate the cartilaginous portion of the eustachian tube using a nasal endoscope rather than by using an invasive surgical technique.

However, there’s a general lack of clarity within the coding community on how to address the coding process behind this increasingly common procedure.

Use these helpful pointers and expert advice to get you on your way to coding each Acclarent AERA ETD System procedure with accuracy and confidence.

Learn How it Works

The Acclarent AERA ETD System is a nasal endoscopic procedure that works to treat patients with chronic ETD symptoms using a minimally invasive technique. First, the surgeon inserts a guide catheter into the nasal canal so that the tip angle of the guide catheter properly aligns with the opening of the eustachian tube. The surgeon then further extends the balloon portion of the catheter into the eustachian tube, up to the point of the isthmus. The balloon is inflated for a period of approximately two minutes. The surgeon then retracts the catheter from the patient’s nasal canal, completing the procedure.

This procedure mimics the technique behind the Acclarent Balloon Sinuplasty procedure, in which the balloon catheter inflates and expands the sinus opening, rather than the eustachian tube.

Get your Coding Advice Straight from the Source

While the balloon sinuplasty offers coders an existing set of CPT^® options (31295-31298), the same cannot be said about the AERA ETD System. Interestingly, CPT^® used to have a code describing this procedure, but subsequently removed it. In place of deleted code 69400 (Eustachian tube inflation, transnasal; with catheterization), CPT^® now advises coders to use the unlisted code 69799 (Unlisted procedure, middle ear) in its place.

“At present, there is not a balloon dilation code for the ear tubes in CPT^®,” states Jennifer M. Connell, CPC, COC, CENTC, CPCO, CPMA, CPPM, CPC-P, CPB, CPC-I, CEMA, owner of E2E Health Solutions in Victoria, Texas. “Physicians should report CPT^® code 69799 for unlisted procedures of the middle ear, such as this. However, keep in mind you will need to reference a code that is similar in respect to work and time,” Connell explains.

Acclarent also officially recommends the use of code 69799 to document its endoscopic eustachian tube dilation technique. However, keep a look out for new codes in the following year(s) to take the place of 69799. Acclarent states, via their website, that, “prior to the implementation of a Category I CPT^® code, the American Medical Association has requirements that must be satisfied. The earliest a Category I code might be available for utilization is January 2019.”

Find a Comparable CPT^® Code

Since you will be billing out the AERA ETD System using an unlisted code, you must first make sure you are able to determine the most accurate code available to use as a proper comparison. “When submitting 69799 for this procedure, you want to give the payer a reference for valuing the service,” says Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, AAPC Fellow, of CRN Healthcare Solutions in Tinton Falls, NJ. “It is best to give them a CPT^® code to compare it to along with a percentage [of work performed] of that CPT^® code so that a value can be assigned to the unlisted code. Place this information in box 19 of the CMS1500 Claim. I usually use 31296 [Nasal/sinus endoscopy, surgical; with dilation of frontal sinus ostium [eg, balloon dilation]] as a guide code for the payers to reference the AERA procedure when submitting 69799, based on what I have been told from my surgeons,” Cobuzzi further explains.

As for alternative coding comparison options, you may want to think twice about code 69420 (Myringotomy including aspiration and/or eustachian tube inflation). While this technique does describe a eustachian tube dilation, it does not account for the endoscopy nor the balloon dilation as described in code 31296.

Via your paper claim submission, you should thoroughly explain the similarities and differences between your selected comparison code and the AERA ETD System procedure. This includes, but is not limited to, comparison operative notes and a written letter by the physician explaining the similarities and differences between the two procedures.

Know When to Bill ETD Procedures with 69436

There are certain instances in which a coder might consider whether or not a tube placement is separately billable in addition to the to eustachian tube dilation procedure. This all depends on the nature and approach of the dilation procedure. If the surgeon performs a dilation using the Acclarent AERA system via a separate nasal endoscope, then you may bill out 69436 (Tympanostomy (requiring insertion of ventilating tube), general anesthesia) separately using modifier 59 (Distinct Procedural Service). However, if the provider performs the dilation via the incision in the tympanic membrane where the tympanostomy is performed, you should bundle the dilation into code 69436. This remains true, even if the AERA system is incorporated into the service.

A representative of Acclarent explains that “the AERA System is not to be inserted via the tympanic membrane and therefore should not be bundled with CPT^® code 69436. The use of the AERA System to dilate the eustachian tube through the tympanic membrane is considered an off-label use of the device.”

Go for Unlisted Over HCPCS Option

Some coders may consider the use of HCPCS code C9745 (Nasal endoscopy, surgical; balloon dilation of eustachian tube) as a more suitable option than 69799. However, you should not consider this code outside of a hospital outpatient department. The Centers for Medicare and Medicaid Services (CMS) states that “C-codes are unique temporary pricing codes established by CMS for the Prospective Payment System and are only valid for Medicare on claims for hospital outpatient department services and procedures.” Most insurance payers, including Medicare, will not reimburse this code when submitted by physicians.