Otolaryngology Coding Alert

Utilize these codes to maximize your provider’s bottom line.

Due to frequency of use, it’s easy to justify not applying as much scrutiny to annual HCPCS Level II updates as you would CPT^® and ICD-10-CM. In addition to some crucial revisions from the AMA to the 2021 evaluation and management (E/M) code set, you should take into consideration a few new denominator exclusion codes for otolaryngology-applicable Merit-based Payment System (MIPS) measures.

While these measures may occur in higher frequency in pulmonology settings, they are eligible for reporting by otolaryngology practices since upper respiratory infections are also treated by otolaryngologists, when applicable.

Bottom line: “It is important for the provider to stay on top of MIPS reporting between the 61 and 85 percent mark in order to ensure a positive payment adjustment, which could be as high as +1.79 percent in 2021,” advises John Piaskowski, CPC, CUC, CPMA, CCC, CCVTC, CIRCC, CGSC, CGIC, COSC, CRC, compliance coder at Shore Physicians Group in Somers Point, New Jersey. “It should also be stated that reporting the bare minimum will result in a neutral payment adjustment and no increase will be applied. Falling below the 60 percent mark will result in reduction in reimbursement of up to minus 7 percent,” Piaskowski notes.

Refresh your knowledge of MIPS denominator exclusions by working your way through these scenarios.

Consider the Following 2 Reworked Measures

Each annual HCPCS Level II manual will typically include new, revised, and deleted denominator exclusion codes. This year, you should focus in on the following two MIPS measures:

• 116 — Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis
• 065 — Appropriate Treatment for Upper Respiratory Infection (URI)

Refresher: Before diving into the new codes, you want to make sure to have a firm understanding of what a MIPS denominator exclusion is, and when to report for it. The three components of any given MIPS measure include a numerator, denominator, and denominator exclusions. Have a look at the Centers for Medicare & Medicaid Services (CMS) definition of each term:

• “The numerator, which is also called the measure focus, describes the target process, condition, event, or outcome expected for the targeted population.
• “The denominator defines the population being measured — it could be the whole population or a subset.
• “The denominator exclusion identifies members of this population who should be removed from the measure population, and hence the denominator, before determining if numerator criteria are met.”

In other words, if a patient falls into a particular category that deems them ineligible for reporting of a numerator code (Performance Met/Performance Not Met), you will report the respective denominator exclusion code associated with the reason for ineligibility.

On top of two existing denominator exclusions for MIPS measure 116, you now have the following two additional denominator exclusion codes for reporting consideration:

• G2176 (Outpatient, ED or Observation visits that result in an inpatient admission)
• G2177 (Acute bronchitis/bronchiolitis episodes when the patient had a new or refill prescription of antibiotics (Table 1) in the 30 days prior to or on the episode date)

Tip: At the very minimum, you should read the measure description and instructions on reporting in order to ensure the patient encounter meets the underlying criteria for MIPS measure reporting. In the case of MIPS measure 116, you’ll report a numerator or denominator exclusion code for any patient aged 18-64 with an acute bronchitis diagnosis. You should also check the denominator criteria to ensure your E/M service code allows for MIPS reporting.

Coder’s note: In addition to the denominator exclusion changes featured here, you can read the other changes associated with these MIPS measures for 2021 in the Otolaryngology Coding Alert (v23n2) articled titled “Prep for Big Changes to Otolaryngology in 2021 MPFS Final Rule.”

Drive the Point Home With 2 Scenarios

Scenario: A 24-year-old patient presents to the office with laryngitis due to coughing from an acute bronchitis diagnosis. The provider opts not to prescribe antibiotics to treat the bronchitis and advises the patient to rest for the next few days.

MIPS coding: This clinical scenario meets the criteria for the “Performance met” numerator. You will report 4124F (Antibiotic neither prescribed nor dispensed (URI, PHAR), (A-BRONCH)) to indicate the provider did not prescribe or dispense antibiotics for a patient 18-64 years old with an acute bronchitis diagnosis.

Scenario: A 24-year-old patient presents for a follow-up visit four days following an acute bronchitis diagnosis that resulted in laryngeal spasming. Despite prescribing antibiotics at the prior visit, the patient’s symptoms have worsened.

MIPS coding: The provider admits the patient into inpatient care. This clinical scenario meets all the criteria required for denominator exclusion code G2176 reporting, since the office visit can be considered an outpatient service.

Set Your Sights on Changes to MIPS Measure 065

You’ll want to take similar considerations into account when reporting MIPS measure 065. Have a look at the following two new denominator exclusion codes for 2021 and beyond reporting:

• G2173 (Uri episodes where the patient had a competing comorbid condition during the 12 months prior to or on the episode date [e.g., tuberculosis, neutropenia, cystic fibrosis, chronic bronchitis, pulmonary edema, respiratory failure, rheumatoid lung disease])
• G2174 (Uri episodes when the patient had a new or refill prescription of antibiotics [table 1] in the 30 days prior to or on the episode date)

MIPS measure 065 looks quite similar to measure 116 in terms of the measure description. You will report a numerator or denominator exclusion code for any patient 3 months of age and older with a diagnosis of upper respiratory infection (URI). However, you’ll see denominator exclusion G2173 varies in that it’s reported when documentation supports a competing comorbid condition within 12 months of the URI. Competing conditions can include, but are not limited to, those referenced in the code description.

Test Your Skills With 2 More Scenarios

Scenario: A 57-year-old-patient presents to the office with a URI and a possible sinus infection. The patient has been following up with the provider bimonthly for the past six months due to ongoing chronic bronchitis and sinusitis. The provider prescribed the patient antibiotics at the prior visit and advises the patient continue to rest until their follow up visit in one week’s time.

MIPS coding: Without a proper understanding of denominator exclusions, or access to 2021 MIPS measures, this could easily be mistakenly reported with “Performance met” numerator code G8708 (Patient not prescribed or dispensed antibiotic). However, in reading the G2173 denominator exclusion code description, you can confirm it’s the correct code to report since chronic bronchitis qualifies as a competing comorbid condition.

Scenario: A 57-year-old-patient presents to the office with a persisting URI and a newly diagnosed case of acute sinusitis. The provider prescribes the patient antibiotics and schedules a two-week follow up appointment.

MIPS coding: Here, you’ve got to consider the full scope of denominator exclusions for accurate MIPS reporting. While the provider did prescribe antibiotics, you will not report “Performance not met” numerator code G8710 (Patient prescribed or dispensed antibiotic). That’s because this clinical encounter meets the criteria for denominator exclusion code G8709 (Uri episodes when the patient had competing diagnoses on or three days after the episode date [e.g., intestinal infection, pertussis, bacterial infection, lyme disease, otitis media, acute sinusitis…]) reporting. While a case of acute sinusitis doesn’t typically seem to be a competing diagnosis to a URI, the documentation supports classifying it as such. Therefore, G8709 is the appropriate MIPS code to report for this encounter.