Otolaryngology Coding Alert

Tip: Tympanic repair will call for separate procedure coding.

Although you'll generally include tube removal as a part of any E/M office visit the physician provides on the same date of service, you should be on the lookout for circumstances that will allow you to report separate services. Keep reading for three instances in which tube removal demands coding above and beyond only an E/M service.

Bundle Removal to E/M -- Usually

In most cases, you should consider ear tube removal to be a component of any E/M service the ENT provides during the same visit.

Assign E/M with caution: Remember, however, that an E/M service includes three key components: history, exam and medical-decision making. If the ENT merely removes the tubes (which can take only seconds) and medical necessity does not require a separate history and/or exam, documentation may not support even the lowest-level E/M service, says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J.

Keep in mind: You need two out of three key components to support a given level of service for an established patient, and three out of three key components to support a given service level for a new patient. However, if the physician does not document a separate history, exam and medical decision making (2 of the 3), but does document that she counseled the patient and parent on care of the ear, indicating the total time and how long the counseling time was, there is a chance that an EM may be selected based on time.

What NOT to do: For in-office ventilating tube removal, you should never report 69799 (Unlisted procedure, middle ear). Likewise, you should not report 69424 (Ventilating tube removal requiring general anesthesia) with modifier 52 (Reduced services) appended. If removing the ventilating tubes does not require a return to the OR with anesthesia, 69424 is never appropriate, Cobuzzi says.

Case 1: Tympanic Repair

If the ENT must perform a tympanic repair (or so-called "paper patch") as a result of the tube removal, you may report this procedure separately using 69610 (Tympanic membrane repair, with or without site preparation of perforation for closure, with or without patch), Cobuzzi says.

If you report 69610, you would not likely report an E/M code in addition unless your ENT documents a significant and separately identifiable E/M service. If documentation supports such a service, however, be sure to append modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to the appropriate E/M service code.

Case 2: Microscope Use

If the ENT must use a binocular microscope to aid in tube removal, you may report 92504 (Binocular microscopy [separate diagnostic procedure]).

Remember: Because 92504 is a "separate procedure," you may only report it if the ENT does not perform any other ear procedures at the same time, Cobuzzi says.

Example: You shouldn't report 92504 with 69210 (Removal of impacted cerumen [one or both ears], for instance, if the otolaryngologist performs both procedures on the same anatomic area. In this case, the "separate procedure" designation with 92504 means you cannot report the procedure in addition to 69210.

Case 3: Removal in OR

When the surgeon removes tubes in the OR under general anesthesia after the 10-day global of 69436 (Tympanostomy [requiring insertion of ventilating tube], general anesthesia) expires, you will report 69424 (Ventilating tube removal requiring general anesthesia) with no modifier appended.

An important point: If the surgeon must return the patient to the OR within the 10-day global period of 69436 for tube removal, you would report 69424 appended with modifier 78 (Return to the operating room for a related procedure during the postoperative period).

Tube removals during the global period of 69436 that do not require a return to the OR are bundled to the tympanostomy. You may not report these services separately. The only exception is if the physician removing the tubes is not the same physician who placed the tubes (or a member of that physician's group practice).

Heads up: On the other hand, for non-Medicare patients, you should not include the treatment of complications in the global period, per AMA guidelines. In other words, if the tube removal was due to a complication for a non-Medicare patient and performed in the office, you can report the tube removal with a modifier 79 (Unrelated procedure or service by the same physician during the postoperative period).

If your physician removes tubes placed by another group practice, you can report an E/M service (as explained above), even if the removal occurs in the office during the 10-day global period of 69436.