Otolaryngology Coding Alert

Warning: Plate stabilization probably won't win you modifier 22 approval. Even though a surgery may require complex steps not included in the CPT descriptor, that doesn't mean reporting additional codes or modifiers will gain the payer's stamp of approval. Use this coding case study to brush up on your tongue tumor resection coding knowledge. Code This Resection Procedure: Total glossectomy for base of tongue cancer via mandibulotomy with plate stabilization. Pre-/postoperative diagnosis(es): Recurrent base of  tongue cancer. Specimens sent to lab: Tongue, free flap, and frozen section biopsies from the areas closest to the tumor. Indications for surgery: Patient, who recently underwent left partial glossectomy and postoperative radiation therapy for recurrent squamous cell carcinoma, presents now with obvious base of tongue recurrence, biopsy proven. He requires definitive resection and free flap reconstruction. Findings in surgery: This patient had a squamous cell carcinoma at the junction of the native tongue and the free flap reconstruction on the left side. Surgeons had to remove the entire tongue since this tumor did cross the midline of the tongue base. Procedure: Surgeons performed a tracheotomy through the patient's previous tracheotomy site, and then opened up the old neck incision. The surgical team then proceeded to perform a midline incision that came up through the chin and split the lower lip. After making the incisions, the flaps were elevated in the subplatysmal plane. After reaching the mandible, surgeons exposed the anterior symphyseal segment of the mandible from the mental nerve to the mental nerve and then extracted tooth #24. Before splitting the mandible, the surgical team bent two plates. After bending the plate and drilling and screwing holes, operating physicians removed the hardware. Then they used the sagittal saw to split the mandible in the midline in a stair step fashion, taking care to preserve both mental nerves. Once surgeons opened the mandible, they used the electrocautery to make some cuts along the floor of mouth, tracking along the left side first. It became apparent that surgical team would have to resect the previously placed flap in order to completely resect this patient's cancer. They started making cuts along the floor of mouth bilaterally, trying to leave a cuff of mucosa to sew a flap to. Surgeons then brought the incisions back onto the base of tongue in the vallecular region bilaterally, allowing the operating physicians to completely remove the tumor, which necessitated the release of the suprahyoid musculature in the region of the hyoid bone.At this point, the surgical team had removed the entire tongue with the previous flap, which they forwarded to pathology for microscopic evaluation. Lastly, surgeons irrigated the wound and the reconstructive team reconstructed the defect. Frozen section biopsies came back negative. Determine Extent of Dissection Finding the correct primary procedure code is first on the agenda. Your two alternatives are: 41140 and 41145, CPT's options for a complete or total glossectomy. Right code: If you chose 41140 (Glossectomy,complete or total, with or without tracheostomy, without radical neck dissection), you are correct! The OP notes describe: "Surgeons performed a tracheotomy through the patient's previous tracheotomy site, and then opened up the old neck incision. The surgical team then proceeded to perform a midline incision that came up through the chin and split the lower lip. After making the incisions, the flaps were elevated in the subplatysmal plane." Why: "There is nothing [here] that describes a radical neck dissection (RND)," says Charles F. Koopmann Jr., MD, MHSA, professor and associate chair at the University of Michigan's department of otolaryngology in Ann Arbor. "An RND would require a much more detailed op note with the appropriate description of the dissection." If there was evidence of an RND, the correct code for this procedure would be 41145 (Glossectomy, complete or total, with or without tracheostomy, with unilateral radical neck dissection). Confirm Services Bundled with Procedure Next, examine whether the surgeons performed any procedures during the total glossectomy that you can report separately. The surgeons performed a mandibulotomy to gain access to the tumor and stabilized the plates during the closure, remarks Julie Keene, CPC, CENTC, otolaryngology coding and reimbursement specialist with UC Health in Cincinnati, Ohio. Since not every glossectomy procedure requires a mandibulotomy, the coder may consider the possibility of reporting this procedure separately or appending modifier 22 (Unusual procedural services) to justify the added work. Explanation: The mandibulotomy is included in a total glossectomy. "The Relative Value Update Committee (RUC) vignette describes [41140] with or without a mandibulotomy and talks about closing the mandibulotomy," says Koopmann. The vignette does not specify how the mandibulotomy is stabilized or closed so this could involve wiring or plate stabilization -- essentally, any method, he adds. Also, the CPT descriptor does not mention that one should report plating separately, Koopmann points out. Conclusion: The mandibulotomy, resection, and closure, therefore, are all included in 44140 and you should not report them separately. Consider 'Unusual' Work Although normal plate stabilization is a part of the closure,there may be cases in which modifier 22 is appropriate to indicate greater than usual work than is normally involved with plate stabilization. Appending 22 might be reasonable when the surgeon is operating in a previously irradiated or operated field. When using modifier 22 in such situations the surgeon must document in detail the added work involved to explain the procedure's marked difficulty. Payers, however, may still deny payment for modifier 22. Solution: Since the patient in this procedure had previously undergone a partial glossectomy and postoperative radiation therapy, 22 would apply in this case. Remember, the op note should carefully delineate the added difficulties the surgeons encountered and also discuss the extra time required to justify 22, Koopmann adds. Source: This operative note is courtesy of UC Health in Cincinnati, Ohio.