Otolaryngology Coding Alert

Question: How do I code for removal of a Zenker's diverticulum when my physician performed the procedure endoscopically? Can I still use 43130?

Answer: No. You won't find any code for the endoscopic removal of the Zenker's diverticulum. You would not use 43130 (Diverticulectomy of hypopharynx or esophagus, with or without myotomy; cervical approach) because it describes an open procedure. Instead, you will need to use an unlisted procedure code such as 43499 (Unlisted procedure, esophagus).

Keep this CPT instruction in mind: "Don't choose a CPT code that merely approximates the service provided." This rule is key for compliant coding; however it leaves you with tough job of submitting a claim without a procedure-specific code.

When you file a claim using an unlisted procedure code you should include a cover letter stating why you are using the unlisted code. This separate report should explain in simple straightforward language exactly what the physician did.

In addition, you need to submit reporting documentation identifying the specifics of the procedure when you file the claim. The supplemental documentation should define the service (nature, extent, need) and the time, effort and equipment required. Other information to include:

• Was the procedure was independent of other services
• Did the doctor carried out additional procedures at the same site
• The number of times the doctor carried out the service at the encounter
• Any extenuating circumstances that complicated the service
• Diagrams or photographs to aid the person reviewing your claim better understand the procedure.

Unlisted procedure codes don't appear in the Medicare Physician fee Schedule, so they don't have assigned fees or global periods. Your payers will generally determine payment for unlisted procedure claims based on the documentation you provide. You can suggest a fee by comparing the unlisted procedure to a similar listed procedure with an established reimbursement value.