Otolaryngology Coding Alert

Here’s what to do when the ENT is doing a membrane repair, too.

When you’re reporting a vent tube removal, you need to tread carefully, because it’s easy to make mistakes like counting the tube as a foreign body or apply modifier 52 when the physician does not use general anesthesia in the OR.

Perfect how you report these procedures by examining the following four tips.

Tip 1: Don’t Confuse Tubes With Foreign Bodies

When you need to code a tube removal, be sure you count it as a tube — and not a foreign body. Ventilating tubes are not foreign bodies. “Removal of tympanostomy tubes in the office setting does not meet the criteria of a foreign body removal [FBR],” according to the American Academy of Otolaryngology — Head and Neck Surgery.

An otolaryngologist has placed the tube there to help drain the patient’s ear. So it is a desired, functional device — not an unwanted object, such as a bead or corn puff. Therefore, you should not use a foreign-body removal code, such as 69200 (Removal foreign body from external auditory canal; without general anesthesia) or 69205 (... with general anesthesia), with 385.83 (Retained foreign body of middle ear) to describe removing a ventilating tube.

Tip 2: Don’t Add Modifier 52 For No General Anesthesia in OR

You would instead report tube removal alone with 69424 (Ventilating tube removal requiring general anesthesia) in an operating room only when general anesthesia is used and the note supports the medical necessity for the general anesthesia. Do not add modifier 52 (Reduced services) to the code to indicate tube removal without general anesthesia.

Tip 3: Use E/M Code and 92504 for Office Setting

If your physician removes the tubes in an office setting, he probably uses a binocular microscope (an operating microscope is only found in the operating room; the equipment is large, unwieldy, and often attached to the ceiling).

Office work: In an office-based situation, your only alternative is to report the removal using an E/M code, such as 99213 (Office or other outpatient visit for the evaluation and management of an established patient...). You will also report 92504 (Binocular microscopy [separate diagnostic procedure]) when the physician uses and documents the binocular microscope. You may want to consider appending a modifier 25 (Significant, separately identifiable E/M service by the same physician or Other Qualified Health Care Professional on the same day of the procedure or other service) if the documentation supports that the E/M service as significant and separately identifiable from the minor service included in the microscopy (92504). Although 92504 has an undefined global period (xxx global days), the Correct Coding Initiative (CCI) version 7.2 indicated that a payer could treat xxx global day procedures in the same way as minor procedures (0 and 10 day global periods) when it comes to including an E/M with the xxx global day procedure.

The E/M can be the decision to perform the removal on inspection or based on the patient’s history (for instance, the otolaryngologist might state that he needed to use the microscope to help get the tubes out). 

Tip 4: Membrane Repair Includes Tube Removal

Physicians sometimes repair a patient’s tympanic membrane and remove ear tubes during the same session, but that doesn’t mean you can report both procedures.

CCI and therefore Medicare and most private payers consider 69424 (Ventilating tube removal requiring general anesthesia) a component of 69610 (Tympanic membrane repair, with or without site preparation of perforation for closure, with or without patch) which is used for “paper patches” and 69620 (Myringoplasty [surgery confined to drumhead and donor area])_with a modifier indicator of “0.”

Remember: A modifier indicator of “0” marked on a code edit signifies that these codes should not be billed together and that only the comprehensive (column 1 code) will be paid regardless of any circumstances for both services. Therefore, in this case, column 2 code 69424 (ventilating tube removal) is already included in column 1 codes 69610 or 69620 (depending on which code is used to close the tympanic membrane opening). CCI does not allow you to use modifier 59 to indicate a separate site because the modifier indicator is “0.”

Most experts agree that including a tube removal in a same-side tympanic membrane repair makes sense. But not allowing a modifier for a tube removal when it is the only procedure performed on that ear does not seem appropriate. Many practices have been known to use modifiers 59, LT, and RT when the tube is removed on one or both sides, but the repair of the tympanic membrane was performed only on one side.  The claim will probably be denied (definitely with Medicare). You should appeal the claim with documentation.