Otolaryngology Coding Alert

Passive pressure opening or active muscular opening usually can easily equalize positive pressure. Negative pressure is more difficult to equalize and requires active dilation of the tube by muscular contraction, such as swallowing and yawning. If negative pressure continues to develop without relief, the tube may become "locked" and require forceful inflation by either Valsalva or Frenzel maneuvers, says R. Paul Fulmer, MD, author of Anatomy and Physiology of the Eustachian Tube, department of otolaryngology, University of Texas Medical Branch in Grand Rounds. "Some individuals can relieve this negative pressure just with swallowing; however, this is variable."

Otolaryngologists may use several studies, such as Valsalva, Frenzel and Politzer, to test the patency or openness of the eustachian tube. Unfortunately, CPT does not provide a code that matches any of these patency or function tests. Some otolaryngologists assign 92567 (Tympanometry [impedance testing]). But 92567 allows payment for the pressure reading only and not the additional tests.

To encourage CPT to identify the studies in the future, you should report unlisted-procedure code 92700 (Unlisted otorhinolaryngological service or procedure), submit the claim on paper and attach an explanation of the study performed. This way, you are coding to the highest specificity and allowing the AMA to collect data on unlisted procedures. The only way to get a new code is through the AMA. You should notify the American Association of Otolaryngologists that there is need for codes to define these procedures, so AAO can lobby for their creation.

In Valsalva, the otolaryngologist takes a pressure reading using a tympanometer. The physician then has the patient try to exhale while pinching his nose and keeping his mouth closed. Asubsequent tympanogram shows whether the tube is open or closed.

The Frenzel maneuver is the opposite of the Valsalva inflation. The patient takes a mouthful of air and, while keeping his mandible open, he closes his lips and pinches his nose. The air in the oral cavity is then compressed by raising the tongue and pressing the cheeks.

In the Politzer test, the physician forces air up the eustachian tube by having the patient close off his soft palate by either saying "k-k-k" or swallowing water, then blowing air into one nostril while the other one is pinched.

The Toynbee test assesses the eustachian tube function by having the patient pinch the nose while swallowing.