Otolaryngology Coding Alert

Make proper use of +69990, 92504 to avoid rejection.

Your ENT has invested training time and money in her telescope or binocular microscope and it's no surprise she wants reimbursement when she uses it.

But when can you separately code operating microscope use? Know the rules and the exceptions to get the dollars you deserve, and to stay out of the auditors- field of vision. Our experts break it down for you.

Numerous CPT codes provide for the use of an operating microscope or telescope. Frequently, separate codes describe similar surgeries performed with and without

these tools.

Surgical example: Say your ENT performs a direct laryngoscopy with dissection and removes a cyst.

If she does not use a microscope, you-d code 31540 (Laryngoscopy, direct, operative, with excision of tumor and/or stripping of vocal cords or epiglottis). If she does use and document the use of a microscope, you-d code 31541 (... with operating microscope or telescope).

In some cases, when there's no mention of a microscope in the code description for a service, you may be able to report +69990 (Microsurgical techniques, requiring use of operating microscope [List separately in addition to code for primary procedure]) or 92504 (Binocular microscopy [separate diagnostic procedure]).

Key: You should report +69990 or 92504 only if the value of the procedure (relative value units, or RVUs) does not incorporate the use of the microscope in the calculation.

That means that depending on the procedures you perform, you may use these codes only rarely. "We never really bother with +69990 since it is considered to be an inclusive component," says Renee Johnson, office manager for Cape Fear Otolaryngology in Fayetteville, N.C. "I did bill +69990 a few times when I worked in plastic surgery."

When your ENT uses a microscope to examine and diagnose a patient in an office or clinic, you may be able to report 92504. Keep in mind that CPT designates this as a separate procedure; that means payers include it in any other procedure done in the same anatomic area. You would only use 92504 if that is the only procedure your ENT performed and documented.

E/M example: Let's say in the clinic your ENT removes tubes from a 13-year-old's eardrum without anesthesia.

Because your ENT isn't using anesthesia on the child, you can't report 69424 (Ventilating tube removal requiring general anesthesia). But, if she uses the binocular microscope to help her see what she's doing, you could report 92504.

If the physician also performs and documents a significantly and separately identifiable E/M at the same encounter as the 92504 -- for instance, 99213 (Office or other outpatient visit for the evaluation and management of an established patient -) -- you will need modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to indicate the documentation supports the E/M service as significant and separately identifiable from the minor service included in the microscopy.

The E/M can be the decision to do the removal. For instance, the ENT might say she needed the microscope to help get the tubes out.

(Note: If your ENT didn't use the microscope, you-d just charge the appropriate E/M.)

Watch out: Only report using an operating microscope for microdissection, not when the ENT uses the scope just to see better. For instance, when your ENT places a tube in the ear, that doesn't require microdissection, so you won't code +69990.

And because +69990 is an add-on code, you should report it only with a related, primary procedure, says Lori Montanez, CPC, coder at SORC in Albuquerque, N.M. You should never report an add-on code alone.

By definition, an add-on code describes a service that occurs only at the same time as another, more extensive procedure. You should list this add-on code on your claim immediately following the procedure for which your ENT performed the microdissection.

All payers are not equal when it comes to reimbursing for +69990. For Medicare payers, an ENT shouldn't expect separate reimbursement with ear procedures, as Correct Coding Initiative (CCI) edits bundle it in. You may have better luck with some private payers.

Medicare just says no: Medicare payers, or any payer that follows CCI guidelines, allow you to report +69990 in far fewer circumstances than payers that follow CPT guidelines. The Medicare Claims Processing Manual, Chapter 12, Section 20.4.5, allows separate payment for use of the operating microscope with only a few codes, none of which apply to ENT practices. Check out the manual online at www.cms.hhs.gov/manuals/downloads/clm104c12.pdf for more details.

For all other procedures, Medicare considers the operating microscope an inclusive component of the procedure and not payable. According to the July 22, 1999, Federal Register, "In specific, payment for primary codes where an operating microscope is an inclusive component will be denied."

Wiggle room: If your patient's payer follows CPT guidelines, you still need to know the restrictions. Check the manual to find instructions on when-- and when not -- to report +69990. Under the header "Operating Microscope," just above +69990's listing, you-ll find a list of codes you can't report +69990 with.

Get it in writing: If you-re not sure whether a payer will accept +69990 with a particular procedure, cross-check the payer's guidelines. Some payers can provide you with a list of which codes they-ll allow with +69990.

Just 1 unit: You should report only one primary procedure per operative session, which means that no matter how many times you use the operating microscope while in the OR, you can report +69990 only once.

You should report only a single unit of +69990, even if the ENT uses both a telescope and an operating microscope during the same session. CPT guidelines preceding endoscopy codes 31505-31579 clearly indicate, "If using operating microscope, telescope, or both, use the applicable code only once per operative session."

Tip: This rule applies even if the surgeon uses the operating microscope for several procedures during the same session. Therefore, if the surgeon bills three surgical codes on one date, you can still only bill +69990 once -- not three times.

Difference in definition: You can use 92504 when your ENT is just looking through the microscope to assist in a procedure. However, +69990 is only for microdissection. So, if the operating microscope is being used to place a tube in a myringotomy incision, your ENT doesn't meet the definition for +69990. To claim +69990, the procedure note must demonstrate that your ENT performed microsurgery and did more than just look through the microscope lens.

Payment cuts averted: When you do apply +69990 appropriately, you should check your explanation of benefits to be sure payers don't apply a multiple-procedure reduction to the code. As an indication of what payers may reimburse you, Medicare's national unadjusted rate for +69990 is roughly $200.