Otolaryngology Coding Alert

NCCI previously included RND code 38720 (Cervical lymphadenectomy [complete]) in glossectomy codes 41135 (Glossectomy; partial, with unilateral radical neck dissection), 41140 ( complete or total, with or without tracheostomy, without radical neck dissection), 41145 ( complete or total, with or without tracheostomy, with unilateral radical neck dissection) and 41150 ( composite procedure with resection floor of mouth and mandibular resection, without radical neck dissection), and modified RND code 38724 (Cervical lympha-denectomy [modified radical neck dissection]) in 41135, 41140 and 41150 by not allowing the use of modifier -59. The new edits contain a modifier indicator of "1," which means a modifier can now be used.

For third-party payers that do not follow NCCI, some coding experts reported bilateral RND with some success. "I would fight the denials and sometimes win," says Julie Robertson, CPC, an otolaryngology coding and reimbursement specialist for University ENT Specialists in Cincinnati. "These new edits should make it easier to get paid for procedures that insurers should have paid all along."

Therefore, when an otolaryngologist performs a complete glossectomy with an RND on the right side and a complete cervical lymphadenectomy on the left side, you should report both procedures with modifier -59 (Distinct procedural service) appended to the component code to indicate a different side. For the glossectomy, which includes a neck dissection on the right side, report 41145-RT(Right side). For the lymphadenectomy (second neck dissection) on the left side, assign 38720-59-LT(Left side).

You may also report a bilateral RND in addition to the laryngectomy code (31365, Laryngectomy; total, with radical neck dissection) and a bilateral modified neck dissection with 31360 ( total, without radical neck dissection), 31365 and 31367 ( subtotal supraglottic, without radical neck dissection), says Barbara Cobuzzi, MBA, CPC, CPC-H, an otolaryngology coding and reimbursement specialist and president of Cash Flow Solutions, a medical billing firm in Lakewood, N.J. Before NCCI 9.0, you could not bill for the second neck dissection, Cobuzzi recalls. "Medicare now allows payment for the second procedure."

So, if an otolaryngologist performs a total laryngectomy with a bilateral radical neck dissection (radical on left, and modified RND on right), you should code an additional dissection, she says. For the total laryngectomy, which includes a radical neck dissection, assign 31365-LT. For the contralateral neck (modified RND on the right side), report 38724-59-RT.

Modifier -59 breaks the edit for a total parotid excision with unilateral neck dissection (42426). Code 42426 includes a unilateral neck dissection. When the excision and RND occur on different sides, you should bill both procedures and append modifier -59 to the component code.

As soon as HCPCS introduced G0268 (Removal of impacted cerumen [one or both ears] by physician on same date of service as audiologic function testing), CMS bundled it with numerous ear procedures and services codes. External ear incision (69000-69020), excision (69100-69155), foreign-body removal (69200-69222) and repair (69300-69320) all include cerumen removal as incidental to the procedure.

Middle-ear introduction (69405-69410), incision (69420-69450), excision (69540-69550) and repair (69610-69676) include G0268. NCCI also bundles the new code into the following special otorhinolaryngologic services: examination (92502), evaluation and treatment of speech (92506-92508), aural rehabilitation (92510), and caloric vestibular test (92543).

The edits contain a modifier indicator of "0," so no modifier can unbundle the code sets. CMS reinforces that it considers cerumen removal an integral part of these procedures and will not make separate payment for it.

NCCI declares several ear procedures as mutually nonexclusive (you can't do one without the other) to ventilating tube removal (69424, Ventilating tube removal requiring general anesthesia). You should not report 69424 in addition to foreign-body removal under general anesthesia (69205), all middle-ear incisions (69420-69450), excisions (69501-69554), repairs (69601-69676), and other procedures (69711-69745). CMS also considers tube removal a component of inner-ear incision (69801-69840), excision (69905-69915), and cochlear device implantation (69930). Basically, these edits make sense. You have to remove any tube prior to performing these procedures.

These edits contain a modifier indicator of "1." So, if an otolaryngologist removes a tube from one ear (69424) and performs tympanostomy (69433) on the other ear, you can report both procedures with modifier -59 appended to 69424 to indicate a different side. Make sure to append the appropriate body-side modifiers to each procedure to identify which sides the procedures occurred on.

NCCI contradicts CPT instructions by bundling intermediate repair (12031-12057, Layer closure of wounds ) and complex repair (13100-13153, Repair, complex ) with benign lesion excision (11400, 11420, 11440), the smallest lesion excision in each category. CPT 2003 added language to the excision-benign lesions subsection: "For excision of benign lesions requiring more than simple closure, i.e., requiring intermediate or complex closure, report 11400-11466 in addition to appropriate intermediate (12031-12057) or complex closure (13100-13153) codes." The edits render this CPT instruction obsolete. However, one would not necessarily see an intermediate or complex closure on a 0.5-cm or smaller lesion, Cobuzzi says.

According to Medicare, NCCI edits take precedence any guidelines in CPT. Although private payers are required to observe the edits, many do, either in whole in part. In this case, coders should follow NCCI's instructions and only code these two procedures separately the appropriate modifier.

For instance, a physician removes a 0.5-cm lesion requiring intermediate repair from a patient's cheek and a .3-cm neoplasm from his neck. For the cheek repair and excision, report 12051* (Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm less), which includes the excision. For the neoplasm excision from the neck, use 11420 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], scalp, neck, hands, feet, genitalia; excised diameter 0.5 cm less) appended with modifier -59 to indicate a separate anatomic site. Check with individual payers before billing.