Otolaryngology Coding Alert

Say goodbye to those tricky temp or -S- codes.

Jumping through the hoops to seek reimbursement for unlisted and experimental procedures is enough to make any coder dizzy. But CPT 2009 comes through for ENT coders with new codes, one of them a long-sought victory on the Epley maneuver, or canalith repositioning procedure (CRP).

So give a big Coding Alert welcome to 95992 (Canalith repositioning procedure[s] [e.g., Epley maneuver, Semont maneuver], per day).

Two procedures to treat obstructive sleep apnea have been added, too, one of which is a win for coders who-ve been slogging through with a temporary Category III code.

Fixing dizziness: The Epley maneuver treats a form of vertigo -- 386.11 (Benign paroxysmal positional vertigo) -- that is caused by small calcium carbonate stones that have moved from the vestibule of the inner ear into the semicircular canals,

where your sense of balance rests. The stones stimulate nerves and cause a spinning sensation, nausea, and unsteadiness.

Sure beats surgery: The patient's head is maneuvered so the calcium crystals roll out of the sensing tube and into another inner chamber of the ear, from which they can be absorbed.

To add to the confusion, sometimes the tiny stones are sometimes spelled "canolith," sometimes "canalith" -- and they may be called otoliths or cupuloliths.

Old codes, old problems: In 2008, you have a HCPCS code: S9092 (Canolith repositioning, per visit). However, Medicare does not recognize the "S" HCPCS codes, so you shouldn't report them to Medicare. Most Blue Cross/Blue Shield and some other commercial payers will recognize the S codes, but such HCPCS codes have no established relative value units (RVU), so you may still encounter payment problems.

The American Academy of Otolaryngology-Head and Neck Surgery recommended coding 92700 (Unlisted otorhinolaryngological service or procedure), which required coders to submit a description of the service with the claim. But Medicare wanted to see the phrase "canalith repositioning procedure," not the common "Epley maneuver," named after the procedure's inventor, Dr. John Epley.

And some carriers and third party payers required the use of physical therapy (PT) codes when coding and billing for the Epley procedure, which created a whole new set of problems given the PT caps.

None of that guaranteed success. Insurers just haven't been paying for the Epley, Peggy Brubaker, office manager at Andover Ear, Nose & Throat Center in Andover, Mass., says. Her coders tried 92700 to no avail. "So now they just bill an office visit code," she says.

No more vertigo: "Now we no longer have this confusion on how to code this service -- 95992" said Barbara J. Cobuzzi, MBA, CPC-OTO, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions in Tinton Falls, N.J. She says final relative values for the new code won't be out until later in November, when Medicare publishes the official fee schedule in the Federal Register.

CRP isn't the only procedure that gets a new code in 2009. Coders whose offices treat obstructive sleep apnea (OSA) - 327.23 (Obstructive sleep apnea [adult][pediatric]) -- will have fresh ammunition soon, with new codes for procedures to reduce snoring.

41512: If your office uses the Repose system, that's the key to code 41512 (Tongue base suspension, permanent suture technique). The procedure involves attaching a suture to a screw in the jawbone and passing the suture through the tongue base. No temporary code referred to this procedure in the past; you would have coded 41599 (Unlisted procedure, tongue, floor of mouth) for this procedure. Medicare has slated 8.46 RVUs for 41512 in the proposed fee schedule.

41530: If your ENT treats OSA with radiofrequency ablation, that's when it's time to look at 41530 (Submucosal ablation of the tongue base, radiofrequency, one or more sites, per session). That code replaces 0088T (Submucosal radiofrequency tissue volume reduction of tongue base, one or more sites, per session [i.e., for treatment of obstructive sleep apnea syndrome]). Medicare appears to have printed an error in the proposed RVUs showing 73.12 for non-facility and 5.57 for facility.

Janet Kidneigh, CPC-A, was pleased to hear about the OSA treatment codes. She works for a physician-billing service in Denver and codes for pediatric ENTs and sleep-study interpretations at The Children's Hospital in Aurora, Colo.

She remembers one of the cases:-"It was a Tricare claim sent in January 2008.-A letter of medical necessity was requested and sent in May.-It was denied again.-As of Oct. 16, our denial team was still requesting the EOB for this denial."

"I think this shows the importance of using Category III codes," Kidneigh says.-"Even if they get denied, at least we may eventually get a regular CPT code assigned to the procedure." Cobuzzi couldn't agree more. "Good job, guys, this is a real success," she says.

Here are some more changes to look for in CPT 2009:

- The wording for intermediate surgical closures changes in CPT 2009. Codes 12041-12047 will say "Repair, intermediate, wounds of neck, hands, feet, and/or external genitalia -." Until now, they said "Layer closure of wounds of neck, hands,feet, and/or external genitalia -." Taking out the words "layer closure" may clear up confusion, as an intermediate repair could also mean a single-layer closure that required extensive cleaning or removal of particulate matter.

- CPT 2009 reinforces what Otolaryngology Coding Alert has been saying all along about +69990 (Microsurgical techniques, requiring use of operating microscope [List separately in addition to code for primary procedure]): Report using an operating microscope for microdissection, not just to see better or when your ENT uses a magnifying loupe. For instance, when your ENT places a tube in the ear, that doesn't require microdissection, Cobuzzi said, "therefore it does not support +69990."

- Notes in the new CPT manual indicate that you won't be able to report two vestibular function tests with an E/M service. Codes 92531 (Spontaneous nystagmus, including gaze) and 92532 (Positional nystagmus test) are now followed by this warning: "Do not report 92531, 92532 with evaluation and management services." Nystagmus tests are vision tests that help diagnose vestibular disorders. This instruction is confusing, particularly if a physician performs the E/M, which may result in the order for the testing, and an audiologist performs the test. This raises the question of whether practices will start rescheduling the patient for the nystagmus on another date. We-ll keep you informed on how to comply with this guideline.