Otolaryngology Coding Alert

Some otolaryngologists push for billing microscopy, leaving coders to battle the appropriateness of claiming 69990 and 92504. Examining the roles and restrictions of these two codes will tune you in to fraudulent-free reporting.

Although Medicare and CPT regulate the use of microscopy codes +69990 (Microsurgical techniques, requiring use of operating microscope [list separately in addition to code for primary procedure]) and 92504 (Binocular microscopy [separate diagnostic procedure]), many physicians continue to report the codes without heeding national guidelines, 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. In fact, CMS permits practices to bill 69990 with only about a dozen codes. In addition, because CPT designates binocular microscopy as a "separate procedure," you can report 92504 only when no other procedure is done on that anatomy, Cobuzzi says.

With all these rules, you're probably wondering when proper coding permits reporting 69990 and 92504. To determine appropriate billing, you must understand each code's definition.

Code 69990 is perhaps one of the most misunderstood procedural codes. Despite its revision in 2002, many otolaryngologists still interpret 69990 as use of an operating microscope based on the code's previous definition (Use of operating microscope [list separately in addition to code for primary procedure]). CPT altered the wording to include "microsurgical techniques, requiring use of operating microscope." The revised definition clarified CPT's intent that physicians report 69990 for procedures involving microsurgery or microdissection rather than as a tool to guide, by magnification or illumination, or otherwise facilitate placements or excisions. Consequently, 69990 does not mean only the use of an operating microscope. "Instead, it is use of microdis-section," Cobuzzi stresses.

This technique describes dissecting tissues under a microscope or magnifying glass, according to Stedman's Medical Dictionary. The physician usually teases the tissues apart by means of needles. "For instance, when grafting a free flap the otolaryngologist may anastomose (join) the blood vessels using a microscope to aid the repair," says Seth M. Goldberg, MD, FACS, owner of Aesthetic Facial Surgery of Rockville in Rockville, Md., and assistant clinical professor of otolaryngologyhead and neck surgery at Johns Hopkins University School of Medicine in Baltimore.

Just because the physician uses microdissection does not mean you should report 69990. CPT allows billing the technique as an add-on service when the primary surgery does not include microdissection as an integral part of the operation. If the procedure already includes microsurgery, such as grafting a free flap with microvascular anastomosis (15756-15758) or microsurgery (15842) and direct laryngoscopy using an operating microscope (31526, 31531, 31536, 31541, 31561, 31571), CPTconsiders 69990 an inclusive component. So, you may not report 69990 in addition to these codes.

The type of equipment and the location in which it's used is one of the key differences between 69990 and 92504. Because 69990 is a very large instrument found only in the operating room, you will not use this code for office-based procedures, Cobuzzi says. "In contrast, 92504 refers to the use of the binocular microscope in an office setting," Goldberg says.

With binocular microscopy, the physician uses the microscope as a visual aid. For instance, an otolaryn-gologist may use the binocular microscope to visualize a deep retraction pocket of the eardrum to determine the presence of a cholesteatoma, he says.

Unfortunately, reimbursement for the office-microscope code is no easier to obtain than for 69990. CPT designates 92504 as a separate procedure, which means you should bill binocular microscopy only if the physician performs no other procedure on that body area during the same visit, Cobuzzi says. Otolaryngologists often use 92504 as a "look see," meaning the physician uses the microscope to view something before he performs a procedure. In this case, you cannot separately report the microscopy.

For instance, during an office visit an otolaryngologist uses the microscope to look into a patient's ear. The physician sees impacted cerumen and removes it. Because the doctor performs the microscopy and the cerumen removal in the same body area the ear you should bill only the cerumen removal (69210, Removal impacted cerumen). Based on microscopy's designation as a separate procedure, CPT does not allow 92504 in addition to 69210 when the doctor performs both procedures on the same anatomy, as in the above scenario. The fact that the physician performed a second procedure in that area excludes reporting 92504 and makes 69210 the only eligible code.

On the other hand, if the doctor looks into the ear with the binocular microscope but does not perform a procedure, you can report the E/M service (99201-99215, Office visit for a new or established patient) appended with modifier -25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) and the microscopy (92504). Remember, NCCI 7.3 changed its global-period language so procedures with XXX global days, such as 92504, include a minor E/M service. Thus, you must append modifier -25 to 99201-99215 to indicate the otolaryn-gologist performed a significant, separately identifiable E/M from the minor service included in 92504.

You may also report microscopy when the physician uses the binocular microscope to look at something that is unrelated to the procedure he performs. Consider an otolaryngologist who performs history, examination and medical decision-making for a patient during an office visit. Based on the E/M, the physician looks in the patient's ear and performs a nasal endoscopy. Because the "look see" is a different body part from the endoscopy, you should report both the binocular microscopy (92504-59, Distinct procedural service) and the scope (31231). You will need to bill 92504 appended with modifier -59 to designate the microscopy as a distinct procedural service from the endoscopy. And, if the physician performs a significant, separately identifiable E/M service, you should report 99201-99215 with modifier -25.