Otolaryngology Coding Alert

You can gain $335 on your thyroidectomy and modified radical neck dissections (MRND) claims while coding appropriately if you've got the correct coding combo. Test your coding prowess with this case study. An otolaryngologist performs a thyroidectomy with central neck/limited neck dissection (level VI) and a bilateral MRND (levels I-V).

• An outside coder recommended coding 60254 (Thyroidectomy, total or subtotal for malignancy; with radical neck dissection) and 38724-59 (Cervical lymphadenectomy [modified radical neck dissection]; Distinct procedural service).

• The otolaryngologist thought the procedure should be coded 38724-50 (Bilateral procedure) and 60252-51 (Thyroidectomy, total or subtotal for malignancy; with limited neck dissection; Multiple procedures).

The outside coder explained that in the first situation, the insurance company might decline to pay one of the 38724s since the payer was paying out a limited neck dissection with 60252 already, relates a California Otolaryngology Coding Alert subscriber. The outside coder felt reporting 60254 as well as 38724 would earn more appropriate reimbursement for the complexity of the procedure. "Which way is correct?" the subscriber asks.

The correct coding for the modified neck dissection (lymphadenectomy with neck dissection) is 38724-50.

The correct coding for the thyroidectomy component is 60252-51.

"I think that 60252 with bilateral 38724 is appropriate," confirms Wayne Koch, MD, professor of otolaryngology, head and neck surgery, and oncology and director of The Head and Neck Cancer Center at Johns Hopkins in Baltimore, Md. "[Code] 60252 is 21 minutes more than the base code 60240 (Thyroidectomy, total or complete) for thyroidectomy only, and that 21 minutes is for limited neck dissection, which would typically be the central neck."

Note: Some payers prefer you to use the left (LT) and right modifiers (RT) rather than modifier 50 (on 38724), shares Cheryl Starner, CPC, revenue integrity analyst at Truman Medical Centers in Kansas City, Mo. Also, opt for modifier 51 rather than modifier 59 with 60252, says Starner, for two reasons: "a. the two procedures have some work in common, and b. they do not hit a National Correct Coding Initiative (CCI) edit."

You should use modifier 59 only when CCI bundles two codes; since 60252 and 38724 are not bundled despite the work overlap, modifier 59 is not appropriate, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CENTC, CHCC, president of New Jersey-based CRNHealthcare Solutions.

Exception: Only if your third-party payer bundles 60252 and 38724, in contradiction to CCI, would you need to append modifier 59 to indicate that the otolaryngologist is performing the neck dissection on a different site from 60252, Cobuzzi says.

Consider 52: An alternate way to code this case would be adding modifier 52 (Reduced services) to 38724 to counter the objection that the payer is already reimbursing for a limited neck dissection with 60252, suggests Charles F. Koopmann Jr., MD, MHSA, professor and associate chair at the University of Michigan's department of otolaryngology in Ann Arbor. "This may be controversial but there is no great, single way to [code] this in my opinion," says Koopmann.

If you were to code 60254 with only one 38724, you would be downcoding a modified neck dissection to a radical neck dissection due to not coding the same sideMRND, says Kathi Flaherty, CPC, with the University of Pittsburgh Medical Center in Pennsylvania.

Code 60254 "adds a radical neck with 30 minutes more intraoperative time over 60252 and 51 minutes more than 60240," explains Koch, who is a member of the American Academy of Otolaryngology-Head and Neck Surgery Physician Payment Policy group.

The neck dissection included in Code 60254 is acomprehensive neck dissection (levels I-V) without preservation of the sternocleidomastoid muscle flap, internal jugular vein, and cranial nerve XI, Koch adds. Most surgeons now do an MRND preserving at least some of those structures, using 38724 to code the procedure.

Look for: The surgical report will show you are in two different areas, removing lymph nodes for the limited neck dissection in Zone VI Paratrachea (central compartment lymph nodes), which are not routinely excised in radical neck dissections, comments Flaherty.

Since the otolaryngologist excised the central compartment lymph nodes as part of a concurrent thyroid surgery, this zone is not considered part of a MRND levels I-V, Flaherty adds.

Catch: By reporting 60254 and 38724-59, you end up losing approximately 9.31 relative value units (RVUs), or $335, from not coding the same side MRND (38724). You would gain 9.92 from coding 60254 (44.94 RVUs) rather than 60252 (35.02 RVUs). The added 9.92 RVUs for 60254, however, doesn't make up for the 19.23 RVUs lost from cutting the same side MRND: 38724 (secondary bilateral procedures pay at 50 percent each or the second MRND would reimburse at half of 38724's total RVUs of 38.45).

Do routine denials for the other side MRND (38724-59) justify just getting the added revenue 60254 provides? If the payer won't reimburse both sides for the neck dissection work, "I would appeal," says Koch.

Why: "The work of the modified neck is greater than for the radical neck dissection, and the bilateral modified necks double the work and time over one side alone," Koch explains. Obviously, if the payer won't pay the second neck dissection, which is already discounted in the 100-50-50 arrangement, then some may choose to report 60254, with 38724-59 -- but this approach is not as accurate in describing the work, he continues.

"Yes, you may need to appeal, but just because you may have to appeal is not reason to incorrectly bill," Flaherty points out.

For some insurance companies you may have to provide documentation to show the difference in the neck dissections but they eventually pay, assures Julie Keene, CPC, CENTC, otolaryngology coding and reimbursement specialist with UC Health in Cincinnati, Ohio.

Bottom line: To code based on reimbursement rather than what the otolaryngologist actually performed is incorrect, concludes Starner.