Otolaryngology Coding Alert

CPT 2002 revised the descriptors of dozens of codes, but most of the changes are cosmetic and do not impact how services are reported.

Revision of Antigen Preparation Codes

Several codes in the Allergen Immunotherapy section have been revised:
 

The addition of the word "preparation" to these codes should eliminate confusion among carriers about how to process claims for both the preparation and the injection of one or more allergens, says Teresa Thompson, CPC, an otolaryngology and allergy coding and reimbursement specialist in Sequim, Wa. CPT now instructs otolaryngologists who provide both components (i.e., injection and preparation of allergens) to do component billing, as none of the complete service codes (i.e., 95120-95134) are appropriate in most circumstances. CPT makes the distinction between injection and provision code clear, explicitly stating that the injection codes do not include "provision" of allergens.
 
Still, many otolaryngology coders report that some carriers have bundled 95165 with 95115 (professional services for allergen immunotherapy not including provision of allergenic extracts; single injection) or 95117 ( two or more injections) even though these codes were not edited in the National Correct Coding Initiative. Many coding specialists attributed the edits to carrier confusion over what was actually covered by 95165, in part because the previous descriptor for 95165 listed only the "supervision of provision" and did not explicitly include preparation (which is the main part of the service).

Modifier -60 Deleted, Modifier -22 Revised

The deletion of modifier -60, which was introduced last year, is a disappointment for otolaryngologists, who often perform procedures that involve altered surgical fields, typically as a result of prior surgery.
 
In 2001, the new modifier was welcomed, and otolaryngologists hoped it would make it easier to obtain additional reimbursement for procedures that were much more difficult because the patient had previously had surgery.
 
Unfortunately, a few weeks after the modifier was introduced, CMS announced that Medicare carriers would not recognize the modifier, and instructed providers to continue using modifier -22 (unusual procedural services).  

The deletion of the modifier in CPT 2002 is an acknowledgment by the AMA that this modifier was not accepted by carriers.
 
"This is unfortunate not only for physicians but also for CMS," 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.
 
"Modifier -60 gave CMS and other carriers an opportunity to collect outcomes data. But because CMS worried about receiving additional claims for unusual and complicated procedures, the code was not accepted."
 
CPT 2001 had amended modifier -22, stating that "this modifier is not to be used to report procedure(s) complicated by adhesion formation, scarring, and/or alteration of normal landmarks due to late effects of prior surgery, irradiation, infection, very low weight ... or trauma (see modifier -60 as appropriate)."
 
Although, at the time of writing, the revision to modifier -22 was not available, it may be assumed that these instructions are no longer valid. With modifier -60 deleted, modifier -22 should be used to report complicated procedures, regardless of the reason for the difficulty, including those involving an altered surgical field.

Microscope Code More Restrictive

Changes in CPT 2002 to the descriptor for 69990, the code for operating microscope, may further restrict payment for this service. The current descriptor for 69990 reads: use of operating microscope (list separately in addition to code for primary procedure). As of Jan. 1, 2002, the descriptor will read: microsurgical techniques, requiring use of operating microscope (list in addition to code for primary procedure).
 
Knowing when and to whom to report 69990 has been complicated since it was introduced two years ago to replace now-deleted 61712 (microdissection) and modifier -20 (microsurgery). Not long after the introduction of 69990, CMS introduced guidelines that restricted separate billing for 69990 for about a dozen codes, none of which are regularly used by otolaryngologists.
 
Many private carriers have continued to pay otolaryngologists for using the microscope, some for techniques, such as tympanoplasty with mastoidectomy and ossicular chain reconstruction, that require microsurgery, and sometimes when the microscope is used in placement or excisions.
 
The new wording makes it clear that CPT's intent was for this code to be used for procedures involving microsurgery or microdissection, but not when used as a tool to guide, by magnification or illumination, placements or excisions or otherwise facilitate placements or excisions. Dorland's Medical Dictionary defines microsurgery, or microdissection, as "dissection of minute structures under the microscope by means of instruments held in the hand, as in microsurgery of the ear and larynx."
 
"By including the term 'microsurgical techniques,' CPT is implying that this code should be reported only when the microscope is used to facilitate microdissection and microsurgery," says Randa Blackwell, a coding specialist with the department of otolaryngology at the University of Maryland in Baltimore. "When you use a microscope with a tympanostomy (myringotomy with tubes), you aren't using the microscope for dissection, you're using it to help you put a tube in the patient's ear."
 
The same applies to cerumen removal (69210, removal impacted cerumen [separate procedure], one or both ears). Also, reporting the operating microscope in addition to cerumen removal is not recommended because 69990 has 5.89 RVUs, but 69210 has 1.66.
 
Even if the commercial payer continues to pay for the tympanostomy or cerumen removal and operating microscope separately, that is no guarantee the coding is correct and will not be questioned later. Therefore, the carrier's decision to pay for the microscope should be obtained in writing whenever possible, says Susan Callaway, CPC, CCS-P, a coding and reimbursement specialist and educator in North Augusta, S.C. "One of the reasons for this new definition is the continued abuse of this misunderstood code," she says.
 
Such procedures as tympanostomy and cerumen removal are good examples of when to bill for an office microscope using 92504 (binocular microscopy [separate diagnostic procedure]). Binocular microscopy enhances the ability to look at the ear canal and ear drum to facilitate tube placement and removal when microsurgery is not needed.
 
This code poses problems, however. First, neither cerumen nor tube removal qualifies as a diagnostic procedure. Second, as a separate procedure, 92504 may be billed only when it is the only procedure performed. Third, and possibly most telling, carriers rarely pay for 92504.