Otolaryngology Coding Alert

Although CPT code 69990 (operating microscope) was introduced less than a year ago, questions already are being asked about its proper utilization and how to obtain reimbursement when the microscope is used.

The problems arise mainly because many commercial carriers continue to refuse to pay for microscope use, just as they did before 69990s introduction, when code 61712 (now deleted) was billed for microscope use in spinal and brain surgery, while modifier -20 (also deleted, component) was designated for all other procedures involving the use of the microscope, according to Susan Callaway-Stradley, CPC, CCS-P, senior consultant in the Medical Group at Elliott, Davis and Co., an accounting and consulting firm in Augusta, GA.

There are a lot of issues regarding this code right now because not all carriers recognize it, and many coders are uncertain about usage, she says. Commercial carriers are beginning to take the stance that if the procedure is done with an operating microscope they wont pay for the use of the microscopes, Callaway-Stradley says.
According to Callaway-Stradley, the rationale is as follows: In the old days, not every hospital had a microscope, so the old code was used to credit the extra expense and the expertise required to utilize the microscope. But now, virtually all physicians trained to perform spinal surgery or nerve procedures use an operating microscope.

The same is true for ENT procedures, such as reconstructing the internal ear. You need a scope to perform those procedures effectively, Callaway-Stradley says.

In other words, commercial carriers are saying that since virtually everybody is using the operating microscope and it is an integral part of the procedure in question, they no longer will reimburse it separately.

Many 69990 denials have more to do with this trend and less to do with problems related to the new code itself, Callaway-Stradley says.

Not For Office Procedures

Commercial carriers aside, there are other issues to remember when coding for microscope use. For instance, Medicare, which does reimburse the use of the microscope, will likely deny a procedure performed in the otolaryngologists office using a microscope if it was billed with a 69990, because it is supposed to be an add-on code used during a surgery or procedure. According to CPT 1999, the surgical microscope is employed when the surgical services are performed using the techniques of microsurgery. Code 69990 should be reported (without modifier -51 appended) in addition to the code for the primary procedure code.

Note: HCFA will pay about $180, depending on geographic location, for the 69990, over and above any other procedure.
The correct code for microscope use during an office procedure is 92504 (binocular microscopy [separate diagnostic procedure]), a special otorhinolaryngologic service code.

Callaway-Stradley says it is difficult, though certainly not impossible, to get reimbursement for either code, so before billing for microscope use, physicians should contact their carriers and find out what they require. This is always good advice, but it is particularly important with new codes like 69990, and with separate procedure codes, like 92504, because they might be bundled into the primary procedure.

Callaway-Stradley calls the 92504 a look-before-you-work procedure, and says the only time 92504 should be billed is if it is the only procedure performed on that day. If the physician uses the microscope to view something during an office visit and then performs a procedure, the 92504 wont be reimbursed (unless the carrier is contacted and says otherwise; in that case, make sure you get it in writing).

In some circumstances, the physician may use the microscope for a purpose unrelated to the primary procedure. If, for example, during a procedure on the patients right ear, the physician uses the microscope to examine the left ear, modifier -59 (separate procedure) should be attached to the 92504, along with modifier -52 (reduced services).

Multiple Microscope Use

Yet another question about 69990 is whether it can be billed more than once if the microscope is used for two or more procedures during an operative session. The question arises because, with the old codes, physicians could add modifier -20 to each procedure and get reimbursed separately for each. Now the question is, do you get extra reimbursement for each procedure, or just one flat reimbursement for the entire surgical session?

The answer is entirely carrier specific, according to Callaway-Stradley, who says she has not seen any HCFA regulations on the issue. CPT, meanwhile, is unclear on the subject, though the code book does say 69990 should be reported in addition to the code for the primary procedure, which could mean that only the main procedure should be billed.

The reference to the primary procedure, however, is vague, Callaway-Stradley says. Some will read it to mean primary procedure for the session, while others will interpret it as the main procedure with add-on codes.

In the end, Callaway-Stradley says, carriers will likely interpret it in a way most likely to reduce their costs. She recommends contacting the individual payer for such claims and getting the response in writing.

Note: Some procedure codes, such as 31526 (laryngoscopy, diagnostic, with operating microscope) specifically ban the use of 69990 in addition to, because the operating microscope is already included.