Otolaryngology Coding Alert

CPT® Guidelines:

Take a Deep Dive Into Access Pathway Concepts With This Guide

Published on Thu May 13, 2021

Drive the point home by coding a few clinical scenarios.

If you haven’t yet familiarized yourself with the National Correct Coding Initiative Policy Manual (NCCI), now is a good time to do so. It offers valuable guidance and coding instruction from specialty to specialty and, more specifically, code range to code range.

Chapter V is where you’ll find instruction on otolaryngology procedural services in the 30000 range. Specifically, much of this chapter is dedicated to the concept of access pathways, in which one surgical service is bundled into another based on the fact that it’s a necessary prerequisite in order to reach the site of the underlying service.

Read on to strengthen your access pathway understanding using the following guidelines and clinical scenarios.

Begin by Defining Key Terms

The NCCI Policy Manual first makes a reference to the concept of access regions, or pathways, here:

“When a diagnostic or surgical endoscopy of the respiratory system is performed, it is a standard of practice to evaluate the access regions. A separate HCPCS/CPT^®code shall not be reported for this evaluation of the access regions.”

The example NCCI Policy Manual cites is the classic instance where you’d bundle a diagnostic nasal endoscopy into an ethmoidectomy, when performed on the same side or bilaterally. However, you want to consider all possible instances where this concept may apply during functional endoscopic sinus surgeries (FESSs) and beyond.

As is the case with numerous NCCI policies, there are certain exceptions you want to be cognizant of. The NCCI Policy Manual states that “if medically reasonable and necessary endoscopic procedures are performed on two regions of the respiratory system with different types of endoscopes, both procedures may be separately reportable.” Keep in mind that a circumstance where an otolaryngologist uses two different types of endoscopes while performing a nuanced respiratory endoscopic procedure is unlikely. Assuming the same endoscope is utilized, there’s no instance where you should bypass the access pathway protocol — even if the physician performs the access procedure for an inherently separate diagnostic reason.

Ultimately, that’s where the underlying confusion comes into play for otolaryngology coders attempting to understand the fundamentals behind the access pathway guidelines. That’s because when you’re learning coding processes, you’re taught that you may override NCCI edits when a significant, separately identifiable service is performed alongside another. This concept was further elaborated upon with the creation of the X{EPSU} modifiers. However, if that significant, separately identifiable service is a necessary prerequisite to access a deeper anatomical level, then you should still bundle the access service into the more comprehensive code.

Consider What Services Do, Do Not Meet Access Pathway Criteria

By the same token, you need to gain a firm understanding, anatomically speaking, of what services are and are not considered access pathways. You should also not limit the access pathway guidelines to surgical services. In some instances, an access pathway service is included in the evaluation and management (E/M) service. Consider a few scenarios to get a better understanding of the access pathways concept.

Scenario: The physician cleans the external ear canal using a binocular microscope in order to adequately visualize the tympanic membrane (TM).

“Access to the tympanic membrane during an evaluation and management examination is considered just that — an access service — and should not be reported separately from the E/M visit,” instructs Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, of CRN Healthcare in Tinton Falls, New Jersey. However, Cobuzzi adds that you may code for the use of the microscope using 92504 (Binocular microscopy (separate diagnostic procedure)).

Round Out Your Knowledge With 3 Scenarios

Scenario: The physician removes impacted cerumen in the right ear in order to access the TM for a diagnostic examination.

This scenario would warrant the coding of the E/M service only. You would only report the E/M service with modifier 25 (Significant, separately identifiable evaluation and management Service by the same physician or other qualified health care professional on the same day of the procedure or other service) and 69210 (Removal impacted cerumen requiring instrumentation, unilateral) if the cerumen was removed contralaterally or in order to address a completely separate diagnostic complaint.

To consider: “Since Medicare Part B treats 69210 as a bilateral procedure despite the AMA description of the code, this scenario would warrant the reporting on an E/M service with modifier 25 and 69210 with modifier 52 [Reduced services],” advises Cobuzzi. Ensure that the documentation establishes that the physician removed the cerumen on the contralateral side due to the patient’s complaint of wax in their ear.

Scenario: The physician performs a left total ethmoidectomy and left frontal sinusotomy in addition to a left maxillary antrostomy with removal of tissue.

Here, you will report all three FESS services as 31253 and 31267 with modifier LT (Left side). Furthermore, neither of these FESS services conflict with one another in terms of the access pathway concept.

Coder’s note: Don’t fall for the fallacy that the absence of an NCCI edit automatically gives you free rein to report a set of codes. NCCI will be there to guide you in the majority of instances, but across specialties, NCCI Policy Manual has been known to restrict coding combinations without an underlying NCCI edit.

Scenario: The physician performs a bilateral total ethmoidectomy alongside a frontal sinus exploration with removal of tissue.

The parenthetical notes under 31276 instruct you “not report 31276 in conjunction with 31237, 31253, 31255, 31296, 31298, when performed on the ipsilateral side.”