Otolaryngology Coding Alert

Even though Medicare has always been impossibly stingy when it comes to reimbursement for intraoperative facial nerve monitoring, knowing whom to bill and how will allow you to fight for all the reimbursement you're entitled to.

Otolaryngologists may provide intraoperative nerve monitoring "to hopefully eliminate the possibility of injury to the facial nerve (cranial VII) during mastoidectomy, parotidectomy and thyroidectomy," says Darlene Reed, CPC, Northland ENT, Liberty, Mo. Intraoperative monitoring is provided with other electro-physiologic studies, such as electroencephalogram (EEG), electromyography (EMG), or nerve conduction studies (NCS), which establish a baseline for comparison during the surgery.

"The time spent performing or interpreting the baseline electrophysiologic study(ies) should not be counted as intraoperative monitoring, but represents separately reportable procedures," CPT states. When reporting intraoperative nerve monitoring, "you must bill the primary procedure first," Reed says.

Two codes describe EMG studies provided to the cranial nerve. When the study is conducted unilaterally, as occurs for ear and parotid surgeries, use 95867 (Needle electromyography, cranial nerve supplied muscles, unilateral). When the study is performed bilaterally, e.g., for thyroid surgeries, assign 95868 (Needle electromyo-graphy, cranial nerve supplied muscles, bilateral).

For ongoing intraoperative testing and monitoring during surgical procedures, CPT designates +95920 (Intraoperative neurophysiology testing, per hour [list separately in addition to code for primary procedure]). In the extensive notes following the definition, CPT instructs coders to use code 95920 in conjunction with the code for the study performed, such as 95867 and 95868. "So, if billing EMG or NCS, 95920 must go with it," says Tara R. Kay-Ritter, appeals coordinator, Atlanta ENT, Allergy & Asthma Associates P.C.

"This code is billed per hour, so report this code by the number of appropriate units," Ritter says. "An hour is reached when 30 minutes has passed, so report two units for 90 minutes."

The 2002 National Physician Fee Schedule Relative Value File divides 95867, 95868 and 95920 into professional and technical components. This means that modifier -26 (Professional component) applies to both of the study codes as well as the monitoring code, Ritter says.

When an otolaryngologist provides the professional component of the study or the monitoring and does not own the equipment, report the appropriate codes appended with modifier -26. The hospital assigns modifier -TC (Technical component) for the cost of the equipment. If you report the global code, the insurer assumes that the physician provided the professional and technical components.

For instance, suppose an otolaryngologist performs a total thyroidectomy. Due to the potential risk of injury to the nerve, the surgeon monitors the nerve for 60 minutes during the surgery, using an EMG to compare the patient's pre-, during and postsurgery status. The surgeon reports 60240 (Thyroidectomy, total or complete), 95868-26, 95920-26.

For the thyroidectomy, the surgeon reports 60240. For the bilateral EMG study, she assigns 95868. For the monitoring, she reports one unit of 95920 to represent one hour of monitoring time. Both codes are appended with modifier -26 to indicate that the surgeon is billing for the professional components only.

 "Medicare will not pay for intraoperative facial nerve monitoring when performed by the operating surgeon," Ritter says. Medicare disregards the position of the American Otologic Society, the American Neurotologic Society and the American Academy of Otolaryngology -Head and Neck Surgery that facial nerve monitoring, including that done by the operating surgeon, should be reimbursed, she explains.

"For billing Medicare patients, it may be a good idea to track the codes at a zero fee," Ritter says, "to track the relative value units and amount of work you are doing.

" However, you should bill third-party payers when the operating surgeon provides the testing and monitoring. "Some private carriers pay," Ritter says. If a payer doesn't consider ENT diagnoses medically necessary, use resources and evidence from the above specialty societies to appeal denials 

Sometimes the otolaryngologist performs the surgery, and a neurologist, co-surgeon audiologist or anesthesiologist provides the testing and the monitoring. For instance, suppose an otolaryngologist performs a parotidectomy, and a neurology technician monitors the nerve for 90 minutes. The otolaryngologist reports the surgical procedure only.

For the surgery, the otolaryngologist reports the appropriate parotidectomy code, such as 42415 (Excision of parotid tumor or parotid gland; lateral lobe, with dissection and preservation of facial nerve). The surgeon's office does not bill for the monitoring, because a neurology diagnostic technician is present, Reed says.

However, if the otolaryngologist uses the monitor alone, the operating surgeon bills 42415, 95867-26, 95920-26 x 2. He assigns 95867 for the unilateral EMG. For the monitoring, he codes two units of 95920. The first unit represents the first hour. The additional 30 minutes qualify for a second unit. The ENT bills for the professional component with modifier -26, and the hospital bills for the technical component with modifier -TC, Reed explains.

 6. Document Time

 "Be very specific in the documentation," Reed says. Be sure to document the start and stop times for the monitor.

To report the interpretation of the study and the monitoring, you must also include a written report, Ritter says. "Make sure that there is clear documentation of exactly why the facial nerve monitoring is required for each case." A medical-necessity statement, such as "Intraoperative nerve monitoring is performed to minimize the risk of injury to the nerve during procedures in which the nerve is vulnerable because of site and/or extent of disease," may assist in getting the claim paid, she says.