Otolaryngology Coding Alert

With parotidectomy, mastoidectomy and acoustics, you can breakout continual measured testing if you don't use the ENT's national provider identifier (NPI).

Try your hand at two case studies that highlight Medicare's criteria for billing 95920 (Intraoperative neurophysiology testing, per hour).

See if you can spot the problem with the following scenario. An otolaryngologist would like to bill the following codes on one claim:

Problem: "Intraoperative monitoring should not be billed by the operating surgeon but rather by the independent physician performing either the global service or the professional component," says Marvel J. Hammer RN, CPC, CCS-P, PCS, ACS-PM, CHCO, president of MJH Consulting in Denver, Colo. "Typically, the physician is either a neurologist or physiatrist (PM&R)."

Alternative: A nonphysician practitioner who is not on the hospital's payroll could bill the intraoperative monitoring separately from the surgeon.

Why: The Correct Coding Initiative (CCI) bundles 95920 into most, if not all, surgical codes, including 42420, Hammer points out. This bundling edit has a status indicator of "0," meaning no modifier can bypass the edit.

Lowdown: The bundle applies on claims in which the same physician reports both the surgical code and 95920. Intraoperative neurophysiology testing (95920) "should not be reported by the physician performing an operative procedure since it is included in the global package," according to the CCI manual, Chapter 11.

Think of it this way. CMS considers monitoring like surgeon-administered anesthesia, which Medicare treats as a nonpayable service.

The edit does not apply if the surgeon reports 42420 and a different provider reports 95920 along with the appropriate baseline study code; "- when performed by a different provider during the procedure, [intraoperative neurophysiology testing] it is separately reportable by the second physician," according to CCI.

Many Medicare carriers include additional restrictions in either articles and/or local coverage determinations (LCD) for intraoperative monitoring. For instance, one Medicare carrier article states, "As an additional physician service, 95920 must be clinically necessary," for example, necessary for patient management and not routinely performed by the anesthesiologist or surgeon.

Caution: Before using 95920, check your major payers- policies. "Many commercial payers have intraoperative monitoring coverage policies and some specifically indicate non-coverage by any provider, for intraoperative monitoring during parotid surgery," Hammer notes.

The otolaryngologist in the previous parotidectomy scenario should report the surgery only. "The physician performing an operative procedure should not bill other 90000 neurophysiology testing codes for intraoperative neurophysiology testing (e.g., 92585, 95822, 95860, 95861, 95867, 95868, 95870, 95900, 95904, 95925-95937) since they are also included in the global package ...," specifies CCI chapter 11.

Don't miss: "Code 95867 is also bundled into 42420 as a component of the surgical procedure," Hammer says. You can bypass this bundling edit only if the surgeon performed the test as a separate and distinct diagnostic study, which is not the case in the above example.

Reason: Code 42420's relative value units (RVUs) account for the additional work associated with preserving the facial nerve, says Barbara J. Cobuzzi, MBA, CPC-OTO, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions in Tinton Falls, N.J. "There are two [total parotidectomy] codes, one with higher RVU's for the nerve preservation." Code 42420 contains 33.50 RVUs compared to 42425 for "total, en bloc removal with sacrifice of facial nerve," which has 21.20 RVUs, according to the 2008 Medicare Physician Fee Schedule.

Case study: An otologist wants to have an audiologist provide intraoperative nerve monitoring during inpatient surgical procedures. The recent transmittals from CMS require qualified audiologists to bill directly for diagnostic audiological services but the memos do not discuss billing for other CPT codes. How should the physician bill for the monitoring and will the group's carrier cover it for Medicare beneficiaries?

"Yes, it is appropriate for an audiologist to be performing intraoperative monitoring," of the eighth nerve (92585, Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; comprehensive) with 95920, says Debbie Abel, AuD, director of reimbursement for the American Academy of Audiology.

Do this: To indicate ongoing eighth nerve testing that could be necessary with acoustic neuroma or posterior fossa surgeries (such as 61520, Craniectomy for excision of brain tumor, infratentorial or posterior fossa; cerebellopontine angle tumor; and 61595, Transtemporal approach to posterior cranial fossa, jugular foramen or midline skull base, including mastoidectomy, decompression of sigmoid sinus and/or facial nerve, with or without mobilization), use 95920 times the number of hours the audiologist provides monitoring in addition to 92585.

Rationale: Code 95920 is not a stand-alone code, points out Robert C. Fifer, PhD, associate professor and director of audiology and speech pathology for the Mailman Center for Child Development at the University of Miami. "It must always be linked to the specific type of diagnostic procedure which, in the case of audiologists, would be 92585." The Medicare Physician Fee Schedule gives 95920 "ZZZ" global days, meaning you must always report the code with another code (such as 92585, 95925, 95926, 95930).

Using 95920 shows that the test "is not simply a one-time measurement of the auditory nerve status," Fifer explains. "Rather, it reflects ongoing, sequential measurements of auditory nerve (for audiologists) or whatever the primary monitoring procedure is.

To break the same-surgeon monitoring and testing with surgery bundle, you have to use the audiologist's NPI.

"You need someone separately credentialed by the payer, such as an audiologist credentialed with her own NPI," Cobuzzi says. The audiologist can separately bill the base code and the monitoring code under only her NPI, not the surgeon-s. Using her own NPI, the audiologist can show she provides the monitoring independent of the surgeon, even if they are members of the same tax ID and practice.

Or else: Billing under the surgeon's Provider ID or NPI indicating that the surgeon did the monitoring would constitute unbundling.

Payment: Medicare covers 92585 when a qualified audiologist bills the audiological function test under her own NPI. Effective Oct. 1, CMS will not pay for audiological diagnostic tests that a qualified audiologist performs and bills under the otolaryngologist's number.

Putting it together: For surgery, such as removal of acoustic neuroma (61530, Craniectomy, bone flap craniotomy, transtemporal [mastoid] for excision of cerebellopontine angle tumor; combined with middle/posterior fossa craniotomy/craniectomy), in which a qualified audiologist brings her ENT group's equipment into the operating room and provides ongoing monitoring of the eighth cranial or auditory nerve with a findings report, you would bill the surgery under the physician's NPI.

Because the ENT's group owns the equipment and the audiologist provides the interpretation, report the global codes (92585 and 95920) under the audiologist's NPI. Using two claims will help show the monitoring and surgery are separate, thus avoiding denials.