Otolaryngology Coding Alert

Question: A patient presented with a left auricular hematoma from a wrestling injury. The physician completed what he documented as complex drainage and a 3.5 cm complex closure. When he evacuated the hematoma, he also excised some dense fibrous tissue. The perichondrium was dissected off the entire conchal bowl because of the hematoma. We billed 13152 and 69005, but Cigna denied the 13152 because of coding edits. Is this correct?

West Virginia Subscriber

Answer: This is one of the uncommon situations when CCI (Correct Coding Initiative) edits consider the higher RVU code, 13152 (Repair, complex, eyelids, nose, ears and/or lips; 2.6 cm to 7.5 cm), to be the Column 2 code to the lower RVU code, 69005 (Drainage external ear, abscess or hematoma; complicated). In other words, the services associated with 69005 include those of 13152 so you should only report 69005.

However: The latest CCI edits state that you can potentially append a modifier to 13152 in order to differentiate between the services provided. Before using this approach, verify that you have sufficient documentation to support billing for drainage and repair. From the description, however, it appears that the location of the hematoma and the repair are in the same area, which doesn’t justify including a modifier to override the CCI edit.

Another approach you can consider is submitting the 69005 with a 22 modifier (Increased procedural services) to account for the extra work involved in the repair. You can submit a corrected claim and appeal the final payment with a description of what was performed along with a copy of the operative note.