Otolaryngology Coding Alert

Question: A patient presented complaining of popping ears. The otolaryngologist examined the patient and performed a right myringotomy with tube (69433). His diagnosis/impression was continuing and ongoing persistent eustachian tube dysfunction with recurrent serous otitis media. Can we bill the procedure and an evaluation and management (E/M), or the procedure only?

Washington State Subscriber

Answer: To bill appropriately for the E/M in addition to 69433 (tympanostomy [requiring insertion of ventilating tube], local or topical anesthesia), says Barbara Cobuzzi, MBA, CPC, CPC-H, an otolaryngology coding and reimbursement specialist and president of Cash Flow Solutions, a consulting firm in Lakewood, N.J., the otolaryngologist would need to document:

The patients history, including a significant history of present illness (HPI), which in this case could include three to four elements, such as associated signs and symptoms (recent virus exposure); duration (how long the patient has had the illness); modifying factors (what makes the patient feel better, or worse); and timing (is the problem worse during the day or night?);

An examination; and

Making a medical decision to perform the procedure (instead of continuing with antibiotics, for example).

In addition, modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) must be appended to the appropriate E/M code.

On the other hand, Cobuzzi argues, if the otolaryngologist looks into the patients ear and decides that because the patients problem has not improved since his or her last visit, a tube should be inserted and only 69433 billed.

The otolaryngologist may choose to examine the patient thoroughly even though only a few weeks may have passed since the last visit, or he or she may take a quick look, see the patients condition hasnt improved and based on that and information gathered from previous encounters decides to place a tube. Although in the second case a cursory examination led to the decision to perform the procedure which is one of the criteria for separately billing E/M on the same day as a visit the exam was not significant. Therefore, modifier -25 cannot be appended to this evaluation, which qualifies only as the preprocedure evaluation component of 69433.

Cobuzzi also notes that to bill correctly for a significant, separately identifiable E/M service, the history, examination and medical decision-making must be documented in the patients medical record.

If the otolaryngologist evaluates the patient before the procedure but fails to document what he or she did, there is no more basis for a claim than the quick decision for the tympanostomy, she says.