Otolaryngology Coding Alert

When an otolaryngologist discovers and excises a retropharyngeal lymph node while performing a tonsillectomy, expectations of additional reimbursement may be inflated. If the node removal was performed without, say, an additional incision, the physician may not be able to bill a separate procedure but bill only for unusual circumstances, says Randa Blackwell, a coding specialist with the Department of Otolaryngology at the University of Maryland in Baltimore.

During a recent session in the operating room, an otolaryngologist performed a bilateral tympanotomy and a T&A. During the course of the tonsillectomy, a retropharyngeal lymph node also was excised. A coder on the physicians staff contacted Otolaryngology Coding Alert to ask how the lymph node excision should be billed and included the physicians operative report, which follows.

Pre-Op Diagnosis: Chronic serous otitis and T&A hypertrophy.

Post-Op Diagnosis: Chronic serous otitis and T&A hypertrophy. Large retropharyngeal lymph node.

Procedure: Bilateral tympanotomy and tube. T&A and excision of retropharyngeal lymph node.

Findings: The patient had enlarged adenoids and huge tonsils but when we removed the tonsils there was a large mass in the retropharyngeal space just to the right of the midline. At first I thought it was an anomalous carotid artery but on palpation there was no pulsation. It was a round movable mass, fairly firm. I suspected it was a lymph node but it could have been some kind of neurogenic tumor or something of that nature.

We elected while we were in there to go ahead and excise it. We simply extended the tonsil incision and developed a retropharyngeal flap and dissected out a lymph node that was about 1.5 cm in diameter. It seemed benign. It was smooth. It did not look like a tumor. We sent it as a separate specimen. I closed the retropharyngeal flap to the posterior edge of the tonsil incision with interrupted chromic sutures. The bleeding was minimal. There was no sign of any large vessels, such as a carotid artery in the area. She tolerated the procedure well.

(Editors note: The remainder of the note covered post-op care and is omitted here.)

The correct coding for this OR session is:

69436: tympanostomy (requiring insertion of ventilating tube), general anesthesia; ICD-9

381.10 (chronic serious otitis media, simple or unspecified).

42821: tonsillectomy and adenoidectomy, age 12 or
over; ICD-9 474.10 (hypertrophy of tonsils and adenoids). 210.9 (Benign neoplasm, pharynx, unspecified).

No separate CPT code should be billed for this lymph node excision because according to the operative report, the physician saw the mass after removing the tonsils, simply extended the incision and removed the nodes, says Blackwell. But modifier -22 (unusual procedural services) might be added if the procedure was complicated by the fact that the retropharygeal masses are not typically found during T&As. If modifier -22 were attached to the 42821, documentation would have to be provided to indicate the excision resulted in an extended procedure, but that is not how the op note above reads, Blackwell says.

The way this op note is written, it sounds as though the node excision was incidental to the T&A, Blackwell says, adding that incidental procedures are usually included in the T&A global period. If the mass had been orapharyngeal (near the tonsils) or nasopharyngeal (near the adenoids) masses, Blackwell says it would typically be viewed as just another piece of tissue.

However, the fact that a retropharyngeal lymph node was excised is significant because the mass is in a different area than what would typically be excised in a T&A session and probably justifies the use of modifier -22 had the documentation been better, she says.

Note: If modifier -22 is attached to the 42821, it
also should be accompanied by a clear and simple cover letter explaining why additional reimbursement is warranted. And dont forget to increase your fee. The payer will not increase it for you. When billing a -22 modifier, you have to increase your fee to reflect the additional work and complexity.

In this case, because the otolaryngologist did not need to make a separate incision and says he simply extended the existing one, a separate code would not be appropriate. But if the procedure were more involved, code 42808 (excision or destruction of lesion of pharynx, any method) might be appropriate.

Although 42808 refers to lesions and not lymph nodes, Blackwell says the difference, from a coding point of view, is semantic, because a word like lesion covers a multitude of events, she says, adding that if the procedure were billed for this operative session, it probably would be ruled as incidental.

Had the otolaryngologist removed the lymph node without the tonsillectomy, then 42808 would be appropriate.

Not Written, Not Done

Another problem with the op report as written is that it makes no mention whatsoever of the bilateral tympanotomy or tube. If the old coders adage not written, not done, were to be applied, the otolaryngologist who performed the procedure shouldnt even be able to bill for those procedures. Without documentation, says Anne Hughes, a practice coder with Mid-Vermont ENT in Rutland, VT, they shouldnt bill for it. Theyll probably get paid, but if theyre audited, they have no documentation of the procedure they have claimed.

The physician should be urged to write an addendum to the original op report indicating that the tympanotomy and tube did, in fact, occur. Failing that, the interoperative report, a handwritten report in the patients chart, should be provided to indicate that the procedure was performed.