Otolaryngology Coding Alert

Otolaryngologists should watch for the new ventilating tube definition change in CPT 2003. It allows any physician to bill for the removal as long as he or she performs the procedure under general anesthesia. In addition, CPT Codes 2003 introduces several revised and new codes that impact otolaryngology:
 

 

the skin end point titration test code has been revised to specify the number of tests

a new Evaluative and Therapeutic Services section includes codes for postsurgery services associated with cochlear implants and for evaluation and swallowing studies (see article 3)

measurement of lesions is now based on the excised diameter (see article 4).

The codes become effective Jan. 1, 2003. Carriers have until April to implement the codes, so check with your payers before using them.

Bill for Same-Physician Ventilating Tube Removal

In 2003, otolaryngologists will be able to use 69424 (Ventilating tube removal requiring general anesthesia) for removing a ventilating tube when the physician performs the procedure under general anesthesia, regardless of whether the physician who originally inserted the tubes also removes them. Previously, only a different physician than the doctor who placed the tubes could report 69424.

"Finally, our doctors can get paid when they are the physician who put in the tubes and are now taking them out, if they need to use general anesthesia," says Barbara Cobuzzi, MBA, CPC, CPC-H, an otolaryngology coding and reimbursement specialist and president of Cash Flow Solutions, a medical billing firm in Lakewood, N.J. "This is a major win for otolaryngology practices."

Added language, which follows the revised definition, clarifies that the pressure equalizing (PE) tube removal code is for a unilateral procedure. For a bilateral tube removal, report 69424 with modifier -50 (Bilateral procedures), according to CPT 2003.

In addition, CPT makes 69424 impossible to report with other ear procedures. A note following the unilateral instruction states you cannot report 69424 with a foreign-body removal under anesthesia (69205), cerumen removal (69210), myringotomy (69420-69421), tympanostomy or tympanoplasty (69433-69676), hearing device implantation/removal/replacement (69710-69718), facial nerve decompression/suture (69720-69745) and inner-ear procedure (69801-69930).

The do-not-report instruction makes 69424 similar to a separate procedure, Cobuzzi says: "You cannot get paid for PE tube removal when it is performed with any of the other ear procedures." Remember, however, when an otolaryn-gologist removes a tube from one ear and performs a different procedure on the other ear, you should report both procedures and append modifier -59 (Distinct procedural service) to the lower-valued code, she says.

For instance, an otolaryngologist removes a ventilating tube from a 3-year-old girl's left ear. While the patient is under general anesthesia, the physician removes a tube and places a paper patch in the child's right ear. Assign 69610 (Tympanic membrane repair, with or without site preparation or perforation for closure, with or without patch) and 69424-59. Report the patch first because 69610 has more relative value units (RVUs) (9.01) than 69424 (2.59). Although these are the RVUs for 2002, the National Physician Fee Schedule Relative Value File for 2003 will presumably grant more RVUs for a patch than for tube removal.

Because the tube removal and the patch occur on different ears, you can report both procedures. You could also append modifiers -LT (Left side) and -RT (Right side) to clarify that the otolaryngologist removed the tube from the left side and placed the patch on the right side. In this case, the claim should read: 69610-RT, 69424-59-LT.

Free Muscle Code Adds Myocutaneous Flap

Code 15756 (Free muscle or myocutaneous flap with microvascular anastomosis) now includes myocutaneousflap and requiresmicrovascular anastomosis. CPT 2002 indicated that it was with or without microvascular anastomosis.

The only thing that differentiates 15732 (Muscle, myocutaneous, or fasciocutaneous flap; head and neck [e.g., temporalis, masseter muscle, sternocleidomastoid, levator scapulae]) from 15756 is that 15756 has the microvascular anastomosis. They both include myocutaneous flaps.

Specify Number of Tests for Skin End Point Titration

CPT changed 95027 from Skin end point titration to Intracutaneous (intradermal) tests, sequential and incremental, with allergenic extracts for airborne allergens, immediate type reaction, specify number of tests.

The revised definition more clearly describes the test, says Charles F. Koopmann, MD, MHSA, professor and associate chair of the department of otolaryngology, physician billing director, and a member of the faculty group practice at the University of Michigan in Ann Arbor. "The code previously referred only to the actual test, and no other instruction was given," he says. CPT now requires that you specify the number of tests.

"CPT changed the wording to almost the exact same thing as 95024 (Intracutaneous [intradermal] tests with allergenic extracts, immediate type reaction, specify number of tests), except it specifies that 95027 is for airborne allergens, and it seems to have kept the 'end point' theory intact," says Chrissy Letsen, CPC, billing coordinator with Metropolitan ENT in Alexandria, Va. Hopefully, the AMA will offer recommendations on how to use the code at the AMA CPT Symposium in Chicago on Nov. 14-15.

In addition, physicians will have to wait to see the full impact of this code until CMS releases the National Physician Fee Schedule Relative Value File for 2003, Koopmann says. Although 95027 for 2002 has no practice expense, perhaps with the definition change CMS will grant work RVUs for 95027. But that is purely speculative.

Remember to Report FNA

CPT 2003 adds reminders regarding fine needle aspiration (FNA) under codes that physicians sometimes perform with biopsies. Although 60100* (Biopsy thyroid, percutaneous core needle) already contained a note, the new CPT adds "For fine needle aspiration, see 10021, 10022" to 42400* (Biopsy of salivary gland; needle). (Use 42400 for parotid biopsies.)

These notes guide physicians who perform needle biopsies, but aren't always doing FNAs, to report the appropriate service when applicable, Cobuzzi says. Including this information with the biopsy codes helps physicians and coders immediately refer to the appropriate FNA codes. "In fact, including 10021, 10022, 60100 and 42400 on superbills is an excellent way to eliminate confusion and remind physicians to report the appropriate services when they are provided, whether they are FNAs or needle biopsies in the appropriate areas," she adds.

Modifier -63 Is for Low-Weight Infants

New modifier -63 (Procedure performed on infants less than 4 kg) reflects the "increased complexity and physician work commonly associated" with neonates and infants up to a present body weight of 4 kg, according to CPT 2003, Appendix A Modifiers. Use modifier -63, unless otherwise designated, with procedures/services listed in the 20000-69999 code series only, CPT states. Do not append modifier -63 to E/M, anesthesia, radiology, pathology/laboratory or medicine codes.

Three codes, for procedures that otolaryngologists perform on small infants, do not allow modifier -63, presumably because the codes already include the extra work. These codes are vestibular stenosis 30540 (Repair choanal atresia; intranasal) and 30545 ( transpalatine) and endoscopy 31520 (Laryngoscopy direct, with or without tracheoscopy; diagnostic, newborn).

These initial restrictions are not necessarily permanent, Koopmann says. Because 30540 is much harder to perform on an infant, otolaryngologists may make a good argument to remove the restriction on 30540 in the future.

Neurology, Neuromuscular Sections Are Redivided

Although CPT 2003 creates several new subsections under neurology and neuromuscular procedures, including Electromyography and Nerve Conduction Tests and Intraoperative Neurophysiology, the changes result in a new organizational structure only and do not change the code definitions. The new CPT groups facial nerve monitoring codes 95867 and 95868, which previously appeared under the subheading Sleep Studies, under the new subhead Electromyography and Nerve Conduction Tests." These codes no longer stand alone. Instead, they use 95860 (Needle electromyography ) as a base code.

For example, 95867 (Needle electromyography, cranial nerve supplied muscles, unilateral) is now ( cranial nerve supplied muscle[s], unilateral). The new Intraoperative Neurophysiology subsection contains only +95920 (Intraoperative neurophysiology testing, per hour [list separately in addition to code for primary procedure]) and maintains the same instructions.

Try New Code for On-Call Service

Otolaryngologists who have privileges at hospitals that require on-call services will be able to code for their services in 2003. Physicians who were previously unable to code for the time hospitals required them to reserve for on-call duty will welcome 99026 (Hospital mandated on-call service; in-hospital, each hour) and 99027 ( out-of-hospital, each hour). "At this time, we are unsure whether Medicare will reimburse for these codes, but you will never know until you try," Cobuzzi says. The same applies to private payers.

Physicians should ask their carriers to make a written determination regarding whether they will accept these new codes, Koopmann recommends. That way, if the payer accepts 99026-99027, the doctor can bill the codes. If the insurer refuses to cover on-call services, and no contractural restrictions exist, the physician may bill the patient.

For physician standby services requiring prolonged physician attendance, you should use 99360, as appropriate, CPT instructs. Do not include time spent performing separately reportable procedures or services.