Otolaryngology Coding Alert

Otolaryngologists sometimes perform surgeries with other specialists. In such cases, coding depends on the answers to a number of questions, such as:
 
1. Did both surgeons perform a part of one procedure, or did each surgeon perform a separately payable service?
 
2. Was there a primary surgeon and an assistant, or did both surgeons have relatively equal roles?
 
3. Does the fee schedule allow the procedure to be billed with modifier -62 (two surgeons)?
 
 
The procedure described in the following article illustrates when modifier -62 may be correctly used to inform carriers that two surgeons (typically, but not necessarily, of different specialties or subspecialties) performed different aspects of the same procedure.

Otolaryngologists As Co-Surgeons

 
Occasionally otolaryngologists are asked to take a biopsy, remove a tumor, or resect a portion of the pituitary gland. When a neurosurgeon schedules the procedure, the services of an otolaryngologist may be requested.
 
The procedure involves accessing the base of the sella turcica (latin for Turkish saddle, a depression across the midline on the superior surface of the body of the sphenoid bone that contains the hypophysis, so named because it resembles a saddle when viewed from the side).  

When the inferior aspect of the sella turcica is accessed through the nose, a small hole is drilled in the skull base, the pituitary gland is identified, and the tumor or malignant tissue is excised. In some cases, a neurosurgeon may ask an otolaryngologist to deal with the nasal approach to the sella turcica, says Sanford Archer, MD, an otolaryngologist and associate professor at the University of Kentucky's College of Medicine in Lexington.
 
"The otolaryngologist typically takes down the anterior wall of the sphenoid sinus and puts the speculum in place. After that, the neurosurgeon takes out the back and superior walls of the sphenoid sinus to get to the sella turcica. Once the pituitary tumor or biopsy is removed, the otolaryngologist closes up," Archer says.
 
The otolaryngologist may approach the sella turcica in several ways, he says, noting that the most common approaches are through the septum via the upper lip. Another approach that is coming into favor uses a nasal endoscopy.
 
Although the sella turcica is a part of the skull base, CPT does not consider the removal of pituitary neoplasms skull-base surgery, notes Lee Eisenberg, MD, an otolaryngologist in private practice in Englewood, N.J., and a member of CPT's editorial panel and executive committee.
 
"This procedure is reported using one code only, whether performed by one surgeon or two," Eisenberg says, adding that although otolaryngologists assist in this procedure, in some cases it may also be performed alone by an otolaryngologist. In this way, Eisenberg says, this procedure is unlike the "official" skull-base surgeries listed in the CPT Manual, which are reported using three separate codes for the approach, the excision/biopsy, and the repair/reconstruction.

Ensure Coding Does Not Resemble Unbundling

 
The correct code for the procedure is 61548 (hypophysectomy or excision of pituitary tumor, transnasal or transseptal approach, nonstereotactic). However, Archer says, some otolaryngologists may incorrectly report one of the following codes:
 

30520 -- septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft
 

31050 -- sinusotomy, sphenoid, with or without biopsy
 

31287 -- nasal/sinus endoscopy, surgical, with sphenoidotomy.
 
 
Archer notes several reasons why otolaryngologists use these codes inappropriately:
 

Their role in the complete procedure may be less than that of the neurosurgeon.
 

The approach to the sella turcica involves resecting the septum and approaching via the sphenoid sinus.
 

They are more familiar with these codes, all of  which describe a portion of what was performed.

 
However, the use of these codes is likely to result in double billing, compliance problems and reduced reimbursement for the otolaryngologist, Archer says. "Carriers are likely to consider billing for an additional code unbundling, because 61548 describes the entire procedure, including the approach," he notes.

Use Modifier -62 for Co-Surgery

 
To bill accurately for the above procedure, both surgeons should use 61548 with modifier -62. (An example confirming the correct use of modifier -62 can be found in the introduction of the 2001 CPT Manual, "Modifiers" subhead, which specifically refers to this situation.)
 
Alternatively, the five-digit modifier may be used as follows:
 

61548 

09962

 
Note: Modifiers are rarely reported with five digits. However, this version might be used if multiple modifiers are reported using modifier -99. In that case, the five-digit codes for the appropriate modifiers would be listed beneath the correct procedure code.

Separate Documentation Crucial to Reimbursement  

 
Co-surgeries billed with modifier -62 usually pay at 125 percent of the rate in the physician fee schedule, which is then split in two by the carrier, each provider receiving 62.5 percent of the total fee.
 
For example, whereas the CMS fee schedule assigns 12.09 transitioned facility RVUs for a septoplasty (30520), 10.95 RVUs to an open sphenoidotomy and 7.09 to an endoscopic sphenoidotomy, the hypophysectomy, or excision of pituitary tumor, is assigned 41.69 RVUs. This translates into about 26.06 RVUs per surgeon after 41.69 is multiplied by 1.25 and then divided by 2.
 
To bill this service as co-surgeons, the otolaryngologist and the neurosurgeon must dictate separate operative reports describing their specific roles. And both practices should communicate to make sure each surgeon used modifier -62. The same diagnosis code(s) would also have to be used, and the documentation of both surgeons must state that they were co-surgeons for the procedure.
 
Note: Assistant surgery (modifier -80) is different from co-surgery in that it does not require a separate operative report. However, the operative report from the primary surgeon must indicate that the assistant was present and assisting the primary surgeon. Assistant surgeons are typically paid between 16 percent (Medicare) and 25 percent (some private carriers) of the fee schedule rate, but the primary surgeon receives 100 percent.
 
CPT guidelines also state that if more than one procedure is performed during the operative session, it is acceptable to bill as a co-surgeon on one procedure and as an assistant surgeon on another. Some private carriers may accept such claims. Many Medicare carriers may not allow payment for a co-surgeon and an assistant during the same operative session. In other words, the surgeon may bill as a co-surgeon using modifier -62, or an assistant using modifier -80, but not both.
 
When a patient's condition requires the talents of two different surgical specialties, but each surgeon is performing entirely separate procedures (which include, but are not limited to, operations involving procedures in the skull-base section of the CPT Manual, 61580-61619), no modifier is required, Eisenberg says. Even if the task performed by the otolaryngologist is similar to that performed during the pituitary excision (i.e., the approach and/or the reconstruction/graft), each surgeon uses the distinct code that describes what he or she did.
 
Note: The CMS fee schedule does not allow co-surgeon or assistant surgeon modifiers to be used for many procedures. Private payers who do not follow CMS' fee schedule may not publish their own lists of procedures that do or do not permit co- and assistant surgery. As a result, otolaryngologists should check with their carriers or be prepared to appeal.   
 
Coding tip: Although the pituitary excision includes the approach, the fat graft used to perform the repair is payable separately. This graft is usually performed by the neurosurgeon, but it may also be done by the otolaryngologist and should be reported using 20926 (tissue grafts, other [e.g., paratenon, fat, dermis]), Archer says.
 
Also, because reconstructive procedures are usually not subject to multiple-procedure guidelines, the fee for performing the fat graft (11.58 RVUs) should not be reduced, he adds. If the carrier inappropriately reduces the fee, the decision should be appealed.