Otolaryngology Coding Alert

4 scenarios show you when to claim surgery-related reimbursement

If you assume that all E/M services in which your otolaryngologist discusses a major operation with a patient are nonreportable, you'll miss ethically deserved payment.

Because CPT includes preoperative visits in a procedure's global surgical package, you may think that you shouldn't code any surgery-related visits. But you should separately report some encounters.

To make sure you don't omit any pre-op pay, test your skills with this quiz.

Patient Requires Surgical Clearance

Question 1: Which CPT code should you report for the following encounter?

A mother presents with her 5-year-old daughter, whom the otolaryngologist previously scheduled for a tonsillectomy and adenoidectomy (T&A) to the physician's office on the surgery date. The otolaryngologist examines the patient to make sure she is healthy enough to undergo surgery and that she still requires the operation. The mother and child then see the surgery scheduler, a registered nurse. The RN explains the operation and answers the mother's surgery questions. The guardian signs the surgery consent forms. The RN sends the patient to the hospital for physician-ordered blood work.

Answer: None. You shouldn't report a code for the patient's visit. "CPT does not have an evaluation and management code for a preoperative visit," says Jessica Loyd, billing manager at ENT Center in Denver. You  should instead include the encounter in the surgical code.

Here's how: You should report 42820  (Tonsillectomy and adenoidectomy; under age 12) for the operation. The code includes the preoperative visit to check the patient's status prior to surgery and perform all necessary presurgical work.

You shouldn't separately report the office visit because it relates to the T&A. "CPT's surgical package includes one related E/M encounter, including history and physical, on the date immediately prior to or on the date of the procedure," says Karen Strickler, assistant manager/billing manager at Southeastern ENT & Sinus Center in Greensboro, N.C.

ENT Decides Patient Needs Surgery

Be careful: Don't assume that CPT's surgical package includes all E/M services that your otolaryngologist performs 24 hours prior to surgery. Sometimes, a patient's encounter may lead to the decision for immediate surgery. In these cases, you should bill the service.

Question 2: Three days after an otolaryngologist admitted a patient with parotitis to the hospital, the patient develops a parotid abscess that requires complicated draining. At that time, the otolaryngologist decides to drain the abscess. Should you report the E/M service?

Answer: Yes, you should report the appropriate-level hospital visit (99231-99233, Subsequent hospital care, per day, for the evaluation and management of a patient) appended with modifier -57 (Decision for surgery) in addition to the parotid drainage (42305, Drainage of abscess; parotid, complicated).

Reason: Because the otolaryngologist made the decision for surgery during that encounter, you should report the hospital visit. The surgery's global period includes a preplanning meeting, but not the encounter in which the otolaryngologist's examination leads him to decide surgery is necessary.

You must append modifier -57 to 42305 because the parotid drainage's 90-day global procedure includes a preoperative E/M service. "The modifier allows payment, bypassing the surgery's global period," Loyd says.

Parents Require Further Counseling

You should also separately report a surgery-related encounter when the otolaryngologist provides further counseling or evaluates a secondary medical problem.
 
Question: Parents return with a child who has had four acute episodes of otitis media in the past six months. The pediatric otolaryngologist had previously recommended tympanostomy, but the parents wanted to hold off before deciding on surgery. The otolaryngologist re-examines the child and offers further advice on performing the operation before the parents consent to surgery the following week.

Answer: In this case, you should report the appropriate-level office visit (99212-99215, Office or other outpatient visit for the evaluation and management of an established patient).

Reason: You should bill an established patient visit when the otolaryngologist documents that he iscusses more than the upcoming surgery, says Andrew Borden CCS-P, CPC, CMA, reimbursement manager in the department of otolaryngology and communication sciences at Medical College of Wisconsin in Milwaukee. The physician must document the exam.

Tip: Borden says that you will usually submit 99212-99215 prior to a surgery in two situations:

1. when the patient needs further counseling

2. when a secondary medical problem necessitates an exam and decision-making.

In the otitis media scenario, the patient's parents require further information and counseling about the procedure. Therefore, you should report the encounter.

You don't need to append a modifier to 99212-99215. The visit occurs outside the tympanostomy's (69436, Tympanostomy [requiring insertion of ventilating tube], general anesthesia) 24-hour presurgery global period.

Patient Delays Surgery

Even though insurers have no way of monitoring payment for office visits that occur outside pre-op surgical packages, you still shouldn't bill preclearance exams during this time frame.

Question: Suppose an otolaryngologist examined a patient three-six months ago and recommended the patient have a septoplasty to correct breathing problems. The patient, however, didn't schedule the operation right away. When the otolaryngologist performs pre-op testing, should you bill a subsequent office visit? asks Cindy McGee, CPC, coder at CSA Ltd. in Philadelphia.

Answer: No, you shouldn't bill 99212-99215 in the above situation.

Reason: "When the otolaryngologist has counseled the patient, and he has decided to proceed with a surgical procedure that contains a global period, you should not bill for a pre-op visit," Borden says.

The visit's timing in relation to the surgery doesn't matter. "When the otolaryngologist performs the visit to apprise the patient's surgical risks and have him sign consent forms, you should include the visit in the procedure's surgical global period," Borden says.

Good news: Even though you shouldn't charge for a presurgical clearance encounter, your otolaryngologist still receives payment for his work. Medicare reimburses global-period procedures at a single dollar amount that pays for surgery-related pre-op, intra-op and post-op work, Borden says.

How it works: CMS assigns each work portion a percentage, usually 10/80/10, Borden says. That means for the pre-op visit and any necessary work, "such as designing flaps, decision-making as to access or incision lines, or whether to use stealth guidance systems," Medicare pays 10 percent of the procedure's total dollar amount. CMS then allots 80 percent of the procedure's payment to the operation's intraoperative work and the remaining 10 percent to the surgery's postoperative work.

For instance, Medicare nationally pays $423.06 for a medically necessary septoplasty (30520 (Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft). Of that fee, CMS designates roughly $42.30 to pre-op work, $338.46 to intra-op work, and $42.30 to post-op work.