Otolaryngology Coding Alert

With the right documentation and modifiers, some practices can earn big bucks

It's getting harder and harder to find payers willing to pay for facial nerve monitoring -- in part because of the latest NCCI Edits (see article on page 59) -- but otolaryngologists who give up entirely on billing for monitoring could be leaving some unclaimed cash on the table.

"I don't think Medicare has ever paid for" facial nerve monitoring, says Rhonda Buckholtz, CPC, office manager at Crawford and Fitch -- Ear, Nose and Throat in Franklin, Pa. But check with your private payers, because some still reimburse for nerve monitoring, Buckholtz says, even though plenty of ENT practices have given up on even billing for it.

While some private payers will pay for nerve monitoring, CPT maintains that it should be done by a separate physician. However, if the EMG is done in a separate pre-op session, you can bill for it.

When coding for facial nerve monitoring, you'll need to follow these expert tips:

When reporting intraoperative facial nerve monitoring, you'll need to use three codes -- one for the primary procedure (the surgery), one for the electrophysiologic study that accompanies the surgery, and a code for the monitoring itself.

Coding for the primary surgery is simple enough, but keep in mind that the National Correct Coding Initiative (NCCI) version 10.2 bundles nerve monitoring into the codes for parotid excisions (42410-42426). (See page 59 for more information.)

For the study, you'll choose one of two codes. If the physician performs a unilateral surgery, such as an ear surgery, report 95867-26 (Needle electromyography; cranial nerve supplied muscle[s], unilateral; Professional component). For a bilateral procedure (such as thyroid surgery) use 95868-26 (... cranial nerve supplied muscles, bilateral). Important: The otolaryngologist must include a professional report for one of these two studies in order to bill for the intraoperative monitoring.

For the monitoring, assign the time-based add-on code +95920 (Intraoperative neurophysiology testing, per hour [list separately in addition to code for primary procedure]). "Remember that 95920 is billed as a unit, and one unit equals one hour," says Tara Kaye Ritter, appeals coordinator for American Physician Services in Atlanta. You can bill for a unit of monitoring when 30 minutes have passed, so if you perform and document 90 minutes of monitoring, you should report 95920 x 2, Ritter says. But for 89 minutes of documented monitoring, you can bill only one unit.

CPT describes the study as "a separately reportable procedure," and therefore you should not factor the time the physician spends performing and interpreting the study into the monitoring. You'll need to keep careful documentation for the time spent monitoring, and "the start and stop times should be very specific," Ritter says. Also, include a short statement about the medical necessity of the monitoring to increase your chances of getting the claim paid.

Use -26

Remember that 95867, 95868 and 95920 are divided into professional and technical components. So when an otolaryngologist performs a surgery with facial nerve monitoring and does not own all the equipment -- as is almost always the case -- you must append modifier -26 to both the study code and the monitoring code. The hospital or surgical center will bill the codes with modifier -TC (Technical component) for the cost of the equipment.

For example, your otolaryngologist performs a total thyroidectomy in a hospital setting and monitors the facial nerve for 100 minutes. For the surgery, report 60240 (Thyroidectomy, total or complete), report 95868-26 for the professional component of the bilateral study, and two units of 95920-26 for the monitoring.