Otolaryngology Coding Alert

Deciphering which excisions are payable together -- and which ones aren't -- isn't always a piece of cake.

Scenario: An otolaryngologist performs 38724 (Cervical lymphadenectomy [modified radical neck dissection]) and the lymph node invades the deep musculature of the neck. Would you code this as:

• 38724, or

• 38724, 21556-51 (Excision, tumor, soft tissue of neck or anterior thorax, subfascial [e.g., intramuscular]; less than 5 cm, Multiple procedures)?

In the above scenario, 38724 alone would be the correct choice, advises Cheryl Starner, CPC, revenue integrity analyst at Truman Medical Centers in Kansas City, Missouri.

Adding 21556 to a neck dissection code does not seem valid, says Wayne Koch, MD, professor of otolaryngology,head and neck surgery, and oncology and director of the head and neck cancer division of the department of otolaryngology at Johns Hopkins in Baltimore. The lymph node excision is already included in the neck dissection codes, you cannot separately bill for this, agrees Julie Keene, CPC, CENTC, otolaryngology coding and reimbursement specialist with UC Health in Cincinnati.

Why: "The neck dissection codes include removal of difficult masses in the estimation of work (using service descriptions that represent typical work)," notes Koch, who is a member of the American Academy of Otolaryngology-Head and Neck Surgery Physician Payment Policy group. "The 2155x series are 90-day global codes with 40 to 120 minutes of intra-service time," Koch says, "I read this to mean they are skin-to-skin resection of a mass (without neck dissection)."

Conclusion: "I would use one or the other, but not both 38724 and 2155x," Koch sums up.

If you feel that you spend far more time and effort than what is usually required, modifier 22 (Increased procedural services) on 38720/38724 is an option, shares Starner.

What to report: When appending -22, include the dollar amount you feel you should be reimbursed. Also, documenting the unusual circumstances in the operative report is key. According to Medicare, you must provide with the claim "a concise statement about how the service differs from the usual" and an operative report, says Starner.

Caution: "Be judicious; overuse of modifier 22 could subject your practice to audits," Starner warns. When you do encounter unusual surgeries that require additional complexity and work, make sure to adequately document the work to support using the modifier.

Mind -- Or Challenge -- CCI Edits

The National Correct Coding Initiative (NCCI) also views lymph node excision as part of neck dissection.

Codes 38724 (and 38720, Cervical lymphadenectomy [complete]) and the 2155x excision codes hit a mutually exclusive edit, points out Starner. A mutually exclusive edit means that you cannot report the procedure codes at the same time (without a modifier), either because one procedure is included in the other or performing them both during the same session would be highly improbable.

Code 38724 is a column 2 code for 21556, but a modifier with code 38724 is allowed in order to differentiate  between the services provided.

To unbundle this pair with modifier 59 (Distinct procedural service), the operative note would have to demonstrate that the otolaryngologist performed the two procedures at different locations of the neck, such as one on the left and one on the right, or that they occurred at different operative sessions in the same day.

Challenge CCI: If you view this, or any, CCI edit as incorrect, you can address your concerns to NCCI Medical Director, National Correct Coding Initiative, AdminaStar Federal, Inc., P.O. Box 50469, Indianapolis, IN 48250-0469, offers Starner.

Be sure to include the following:

1) specific information on what edits you feel are inappropriate

2) why you feel these edits are incorrect, with supporting documentation

3) clinical literature

4) coding guidelines.