Otolaryngology Coding Alert

AAO-HNS confirms -traditional- service coding for this procedure

Although alternative surgical CPT codes may tempt you when coding for your otolaryngologist placing an ear wick, the tried and true is the way to go.
 
Problem: -There is no specific code for placing an ear wick,- says Robert W. White, practice administrator at Eastern ENT Sinus and Allergy Center PA in Goldsboro, N.C. Payment depends on the insurer, he adds.

Understand the Procedure

Before trying to code ear wick placement, get a grip on what the procedure involves. The otolaryngologist places an ear wick as a surgical procedure to treat conditions such as otitis externa (380.12, Acute swimmers- ear) and diffuse acute otitis externa (380.10, Infective otitis externa, unspecified). It is not a diagnostic procedure, White says.

The physician applies liquid medication to a sterile, compressed sponge, which gently and evenly expands to fill the ear canal, dispersing the medication and applying gentle pressure to the tissue. He inserts the sponge gently, usually under direct visualization, taking care not to push it in too deep.

Ditch These 2 Methods

Some coders may propose the erroneous idea that you could use 69200 (Removal foreign body from external auditory canal; without general anesthesia) for ear wick placement. The false rationale: An ear wick is a foreign body, which makes 69200 similar, except the code describes removal, rather than placement.

Problem: CPT warns against using codes that -approximate- services or procedures. Code 69200 is inappropriate for placement because one is using a -like- code, says Michael Setzen, MD, FACS, FAAP, chief of rhinology at North Shore Otolaryngology Associates in Manhasset, N.Y.

Instead of using an approximate code, some coders incorrectly suggest reporting the placement with the external ear unlisted-procedure code 69399 (Unlisted procedure, external ear). The false reason purports that because the procedure is surgical and involves the external ear -- but CPT doesn't contain a specific code for the procedure -- the code for an external ear surgical procedure is appropriate.

You should instead reserve the unlisted-procedure code for novel procedures, says Hayes H. Wanamaker, MD, chief of otolaryngology at Crouse Hospital in Syracuse, N.Y. -The RVU comparable value and expected reimbursement would be so low that it wouldn't be worth the hassle of providing the documentation and fighting for reimbursement,- he adds.

Include the Placement in the E/M Service

Traditionally, otolaryngologists have leaned toward using 99201-99215 (Office or other outpatient visit) to
represent the work involved in ear wick placement. -I have routinely included insertion and removal of an ear wick as part of the E&M code,- Setzen says.

Official guidance: The American Academy of Otolaryngology -- Head and Neck Surgery (AAO-HNS) confirms that you should include the ear wick placement in the E/M code you report for the associated history, examination and medical decision-making that resulted in the insertion. -It is our stance that this service is most appropriately captured as part of the E/M service,- says Linda T. Ayers, MHCM, senior director of health policy for the AAO-HNS in Alexandria, Va. -The work and time involved in the process is minimal,- she tells Otolaryngology Coding Alert.

Add About $25+ to the Claim

Don't overlook reporting visualization, which can add about $26 to the claim. If the microscope was used to place the wick, you can report 92504 (Binocular microscopy) as well as the E/M service, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC, director of outreach programs for the American Academy of Professional Coders based in Salt Lake City. The Medicare Physician Fee Schedule assigns 0.70 transitional nonfacility relative value units to 92504 (0.70 x 2007 conversion factor 37.8975 = national unadjusted rate of $26.53).

Warning: Avoid automatically assigning 92504 on encounters involving ear wick placement. Use the code only when the encounter meets three criteria:

1. Binocular microscopy was necessary, Setzen says.

2. The otolaryngologist documents using the microscope, Cobuzzi says. Code 92504 is for the visualization, not for the ear wick placement.

3. When the ENT performs no other codeable ear procedure during the same visit. CPT designates binocular microscopy as a -separate procedure.- This designation means that if the physician performs any other ear procedure, the binocular microscopy is incidental.

Use 25 to Designate Separate E/M Service

Before reporting 92504 in addition to an E/M service, such as an office visit (99201-99215) or consult (99241-99245, Office or other outpatient consultation), make sure the encounter meets the criteria for modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service). The otolaryngologist must provide and document the E/M service as a significant, separately identifiable service from the binocular microscopy.

Why: The National Correct Coding Initiative (CCI) version 7.2 added a small E/M service to codes containing an XXX global period, such as 92504. Therefore, the physician must perform more than just a minor, related E/M service to report and expect payment for the service. When the E/M service is significant and separately identifiable from the binocular microscopy, attach modifier 25 to the E/M code, Cobuzzi says.

Example: An established patient presents with severe otalgia associated with otorrhea and a history of recent water exposure. The otolaryngologist cleanses and debrides the ear and diagnoses -swimmers- ear.- He then inserts an ear wick, using a microscope, into the swollen external auditory canal to allow penetration and uniform distribution of the ototopical agent.

Solution: Report the appropriate-level office visit (such as 99213-25) based on the history, exam and medical decision-making that the otolaryngologist documents, as well as the nature of the presenting problem. Because the otolaryngologist indicates he placed the wick under direct microscopic visualization, assign 92504 for using the microscope. You should link 99213-25 to the sign and symptom of otalgia (388.70) and 92504 to swimmers- ear (380.12) and otorrhea (388.60).