Otolaryngology Coding Alert

Coders can sometimes let a global period confound coding facts and they end up under-coding post-op services, which leads to under-payment, of course. Don't make the same mistake: Learn when to separately report hardware removal from the following case study.

Case: The patient had open reduction internal fixation of two fractures and was placed in intermaxillary fixationfor two weeks. Following the fixation period, the patient presented for removal of arch bar implants (maxillary arch bar hardware). The surgeon completely removed the arch bars and wire and wire fragments from the Erich arch bar and released the arch bar from the teeth.

A coding tip for 21470 (Open treatment of complicated mandibular fracture by multiple surgical approaches including internal fixation, interdental fixation, and/or wiring of dentures or splints) indicates that removal of a fixation device is not separately reportable. Does this mean I cannot report for the arch bar removal? asks a coder at Proliance Orthopedics and Sports Medicine in Bellevue, Wash., who provided this case study.

Don't dismiss removal codes, such as 20670 (Removal of implant; superficial), as always included in the primary procedure.

Surgeons place arch bars to guide the occlusion for mandible repair. While some patients are taken out of fixation at the end of the surgery, others are left in fixation for a month, notes Julie Keene, CPC, CENTC,  otolaryngology coding and reimbursement specialist with UC Health in Cincinnati, Ohio. For the latter patients, billing for the removal separately makes sense, Keene comments.

"I would definitely use 20670" to report the hardware removal in this scenario, says Kathi Flaherty, CPC, with the University of Pittsburgh Medical Center in Pennsylvania.

AAO view: "Our stance is that, based on the CPT Assistant article and a lack of written vignettes to the contrary, 20670 (not 20680, Removal of implant; deep) can be reported for removal of arch bars," says Linda Ayers, MHCM, CAE, senior director of health policy with the American Academy of Otolaryngology-Head and Neck Surgery in Alexandria, Va.

Report 20670 for arch bar removal at "any time in the global or out of the global period," advises Flaherty. CPT Assistant, December 2007, confirms that this approach is correct, she adds.

"The removal of arch bars placed in the treatment of a fracture is a separately billable service and not included in the global package of the fracture repair surgery -- regardless of who (same surgeon or different surgeon) placed the arch bars in the first place," concurs the American Association of Oral and Maxillofacial Surgery (AAOMS) on its Web site: www.aaoms.org/faq_coding.php#1.

Some payers may require that you append a modifier if the surgeon performs the removal within the global period of the initial surgery. "If within the global, you would have to append modifier 58" (Staged or related procedure or service by the same physician during the post-operative period), notes Flaherty.

Some patients have the arch bars removed in the clinic and those who cannot tolerate the removal in clinic receive the service in the operating room, says Keene.

Depending on the place of service (POS), use either office (11) or hospital operating room (21, Inpatient hospital) with 20670. Of course, performing this in the office, if the patient's condition permits, is preferable, since it leads to better reimbursement versus in the hospital, offers Flaherty. Code 20670 has 9.8 nonfacility relative value units (RVUs, approximately $354) compared to 3.85 facility RVUs ($139), using the 2010 Medicare Physician Fee Schedule. The fee difference is because the facility would cover the supply cost if the physician performs the procedure in the facility, whereas the physician's office would cover the cost when performed there.