Otolaryngology Coding Alert

Some otolaryngologists have reported using 69200 (removal of foreign body from external auditory canal; without general anesthesia) or 69205 (with general anesthesia) to get paid for removing PE tubes long after the global period for the original tympanostomy has ended. The American Academy of Otolaryngology-Head and Neck Surgeons and otolaryngology coding experts agree that billing for the removal of tubes this way is inappropriate.

The tubes that were inserted during a tympanostomy (69436, tympanostomy [requiring insertion of ventilating tube], general anesthesia) or 69433 (tympanostomy [requiring insertion of ventilating tube], local or topical anesthesia) sometimes need to be removed if they do not come out on their own. The otolaryngologist cannot bill separately for taking them out, however, because the removal regardless of how long after it occurs is considered part of the global period if it is performed by the same physician, even though 69436 has only 10 global days.

CPT guidelines currently allow billing for removal of tubes only if the tubes were inserted by another physician. This procedure is coded 69424 (ventilating tube removal when originally inserted by another physician).

Note: A physician operating under the same tax identification number as the doctor who performed the original tympanostomy also cannot bill 69424.

The wording of 69424 implicitly clarifies CPTs position even though the tympanostomy code does not refer to removal of tubes, says Barbara Cobuzzi, MBA, CPC, CPC-H, an otolaryngology coding and reimbursement specialist in Lakewood, N.J.

Foreign Body Removal Code Is Inappropriate

Many otolaryngologists believe that including tube removal in the fee of the original tympanostomy (often performed months or years later) is unfair and goes against CPT conventions (for example, even related services during the global period of a primary procedure often are paid if the correct modifier is attached). Because code 69424 explicitly rules out tube removal by the same physician who inserted the tubes, some otolaryngologists, in their frustration, are using the removal of foreign body codes to gain reimbursement and some carriers are paying for such claims. That, however, does not mean it is correct.

PE tube removal by the same physician cannot be billed as a foreign body removal under any circumstance, says Eileen M. Giaimo, assistant director of socioeconomic affairs with the American Academy of Otolaryngology-Head and Neck Surgeons. It is not a foreign body. While sympathizing with the otolaryngologists on this issue, coding experts warn that even if a carrier pays for the foreign body removal, that does not mean it would stand up in the event of an audit.

Practice Correct Coding

There are several reimbursement strategies, however, depending on the circumstances and the procedures performed, that, when appropriately billed, could compensate otolaryngologists for ancillary work, such as evaluation and management (E/M) visits or patches that also are performed during the same visit the tubes are removed.

For example, an otolaryngologist who has been seeing a three-year-old girl with chronic ear infections decides to place tubes in both ears to reduce the frequency of infections. A bilateral tympanostomy with general anesthesia (because the patient is a young child) is performed and coded as follows: 69436, 69436-50 or 69436-50.

Note: Because the payer in this case is a commercial carrier (as children arent covered by Medicare), the procedure may have to be coded on two lines. Some carriers also may prefer -LT (left side) or -RT (right side) modifiers in place of or alongside modifier -50 (bilateral procedure). Check with the carrier to find out how many lines they want and which modifiers they prefer.

The procedure has a global period of only 10 days, but the otolaryngologist continues to monitor the patient for six months. The visits, of course, are billable using the appropriate level E/M code in the 9921x series (established patient). If the otolaryngologist uses a microscope to inspect the tubes and the tympanic membrane, then code 92504 (binocular microscopy [separate diagnostic procedure]) should be billed, but an E/M visit could not be charged as well, unless the doctor also was examining another unrelated problem, such as adenoid hypertrophy (474.12). In this case, an appropriate level of E/M could be billed with the -25 modifier (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

Documentation Must Follow

After 10 months, the girl has remained infection free, and the otolaryngologist decides to remove the tubes. Because there likely would be discussion about current problems, preventive care and treatments, an established patient visit code (99211-99215) that reflects the total service provided by the physician on that day could be billed, as long as there is documentation in the patients medical record to support the visit.

In this case, because of the childs young age, the otolaryngologist decides to perform the procedure under general anesthesia. If the physician simply removes the tubes and performs an exam to make sure everything is OK while the child is anesthetized, code 92502 (otolaryngologic examination under general anesthesia) should be billed in place of the E/M service, Cobuzzi says.

This time, however, the otolaryngologist uses the microscope and determines that one of the eardrums that was cut to allow the tube to pass through requires repair. Some otolaryngologists consider the repair part of the removal and dont bill for it, but they are missing out on a reimbursement opportunity because the two services are separate.

The physician elects to perform a relatively simple repair of the eardrum commonly known as a paper patch (69610, tympanic membrane repair, with or without site preparation or perforation for closure, with or without patch).

Note: Sometimes the damage to the eardrum may be such that it requires a trip to the operating room for a tympanoplasty. In that case, the correct procedure code would be 69631 (tympanoplasty without mastoidectomy [including canalplasty, atticotomy and/or middle ear surgery], initial or revision; without ossicular chain reconstruction).

Currently, billing for an E/M visit along with tympanic repair and exam under anesthetic, represent the only ways to be reimbursed appropriately for procedures and services performed in conjunction with removal of PE tubes by the same physician who inserted them. And the situation is unlikely to change soon.

Although otolaryngologists have put the case to the American Medical Association (AMA) to create a CPT code for removal of tubes by the same physician who inserted them, little progress has been made so far. This is, and continues to be, an ongoing battle we fight with the AMA, Giaimo says.