Otolaryngology Coding Alert

Question: Is 43130 correct for an endoscopic staple-assisted Zenker's diverticulectomy? The code descriptor specifies -cervical approach- rather than -endoscopic,- but I can find no other code that seems correct.


South Carolina Subscriber

Answer: Otolaryngologists traditionally used an open transcervical approach (43130, Diverticulectomy of hypopharynx or esophagus, with or without myotomy; cervical approach), which requires a lateral neck incision, to remove a Zenker's diverticulum, or ZD (a back-of-the-throat pouch). As you correctly note, however, 43130 does not describe an endoscopic procedure.

Physicians increasingly prefer the endoscopic stapling procedure, which requires no incisions and resects the common wall with a gastrointestinal stapler. Unfortunately, CPT doesn't yet contain a code for noninvasive endoscopic staple diverticulectomy. Therefore, your best bet is to report the unlisted-procedure code 43499 (Unlisted procedure, esophagus).

Another advantage of unlisted-procedure codes: Payers such as CMS -ration- relative value units (which determine physician payments) among specialties. When you (correctly) use an unlisted-procedure code, it tells payers that a new code may be needed to describe that procedure. If and when the AMA designs the new code, it will -create- new relative value units (RVUs) for the specialty as well.

If you use modifier 22 with a listed code, in contrast, the AMA may create a new code to describe the -more extensive- procedure, but it will simply -redistribute- RVUs within the specialty to create value for the new code rather than adding to the overall RVUs available within the specialty.

As with any claim that includes an unlisted-procedure code, you should submit the claim electronically and send back-up documentation. You should include a cover letter explaining the procedure with your claim. You should also compare the procedure performed with a similar procedure that does have a dedicated CPT code.

You can give a -percentage- estimate of the amount of work involved in the unlisted procedure. For instance, you can state, -This procedure involves about 80 percent of the physician work and resources involved in the similar listed procedure XXXXX.- This will help the insurer to make an informed payment/coverage determination.

For instance, in this case, you could state, -Endoscopic stapling involves similar intra-operative work as traditional ZD removal as described by 43130, but the endoscopic procedure is less invasive and generally results in faster patient recovery and fewer complications.-

Additional tip: See -Paper Claim Doesn't Have to Mean Slow Filing- within this issue for an important documentation and claims processing tip.

Learn more: For complete information on reporting unlisted- procedure codes, see -3 Tips Mean -Unlisted- Doesn't Have to Mean Unpaid- in the December 2005 Otolaryngology Coding Alert.

For more information on ZD procedures from the America Academy of Otolaryngology/Head and Neck Surgery (AAO/HNS), visit their Web site at www.entlink.net/practice/resources/Refresher-on-how-to-code-Zenkers-Diverticulum.cfm.

Clinical and coding expertise for You Be the Coder and Reader Questions provided by Barbara J. Cobuzzi, MBA, CPC, CPC-H, CHBME, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J.; and Charles F. Koopmann Jr., MD, MHSA, professor and associate chair at the University of Michigan's department of otolaryngology in Ann Arbor.