Otolaryngology Coding Alert

Although an otolaryngologist may not bill for ear tube removal when he or she performed the tympanostomy (69436, tympanostomy [requiring insertion of ventilating tube], general anesthesia; or 69433, local or topical anesthesia), the physician can be reimbursed when providing care related to the procedure.

During a tympanostomy, the otolaryngologist makes a small incision in the patients eardrum to suction off fluid in the middle ear and inserts a ventilating tube. The procedure, which is often bilateral, is typically performed on patients with chronic ear infections. Children tend to require the procedure more, but it also is performed on adults.

The tubes that were inserted during the procedure may need to be removed later if they do not come out on their own. The otolaryngologist cannot bill separately for removing them, however, because the removalregardless of how long after the tubes insertionis considered part of the original procedure if it is performed by the same physician, even though 69436 has only 10 global days. Some otolaryngologists believe they can use codes 69200 (removal foreign body from external auditory canal; without general anesthesia) or 69205 (with general anesthesia), but billing these procedures for removing tubes they originally inserted is incorrect because the removal is bundled into the original insertion code, says Teresa Thompson, CPC, an independent reimbursement and coding specialist in Carlsborg, WA.

But other services performed after the original tympanostomy may be billable. For example, a four-year-old child with chronic ear infections has been prescribed antibiotics every other month for his condition, and his otolaryngologist finally decides that the boy would benefit from tubes placed in both ears.

The physician schedules surgery and, because the patient is a young child, decides to use general anesthesia. The surgery should be coded 69436 with a -50 modifier (bilateral procedure) attached. Because the payer in this case is a commercial carrier (as children arent covered by Medicare), the procedure probably should be coded on two lines as follows:

69436
69436-50

Note: Some carriers may prefer -LT (left side) and
-RT (right side) modifiers in place of or alongside modifier -50. Check with your carrier to determine how many lines they want and which modifiers they prefer.

E/M May Be Billed for Follow-up Visits

Although the tympanostomy has only a 10-day global period, the otolaryngologist continues to monitor the patient for six months. The follow-up visits, of course, are billable using the appropriate level evaluation and management (E/M) code in the 9921x series (established patient).

Occasionally, however, the physician must use a microscope to inspect the tubes and the tympanic membrane. These visits would be coded 92504 (binocular microscopy). An E/M visit should not be charged in addition to this unless the doctor also is examining a separate unrelated problem, such as adenoid hypertrophy (474.12), in which case an appropriate level of E/M could be billed with modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended.

After about eight months, the boy has remained infection free and the otolaryngologist decides to remove the tubes. If the patient is an adult, the physician would perform an evaluation and probably remove the tubes in his or her office.

Although the tube removal cannot be billed if it is performed by the same physician who inserted them, it is unlikely that a patient would return only for the removal of the tubes. There would likely be discussion regarding the response to treatment, any current problems, preventive care, etc, says Emily Hill, PA-C, a member of the American Medical Associations (AMA) Relative Value Update Committee, correct Coding Policy Committee and CPT-5 Project and the managing partner of Hill and Associates, a coding and reimbursement firm in Wilmington, NC.

In that case, an E/M code reflecting the total service provided by the physician on that day could be billed, she says, adding that the level of service would be based on the extent of the history, exam, and medical decision-making. If counseling (e.g., concerning infection prevention measures) dominated the encounter, then the E/M level could be selected based on the time spent counseling. Of course, the E/M code would have to be supported by documentation in the medical record.

If the physician determines that he or she must remove the tubes under general anesthesia because of the childs age and performs an exam to make sure everything is OK while the child is anesthetized, code 92502 (otolaryngologic examination under general anesthesia) may be billed in place of the E/M service, says Christine Schorb, administrative coordinator of medical records for the Department of Otolaryngology at Washington University Medical School in St. Louis, MO.

Note: There is only one circumstance when billing for removal of tubes is permitted, Schorb says. If a different otolaryngologist from a different group removes the tubes. In this instance, the removal can be charged using code 69424 (ventilating tube removal when originally inserted by another physician), regardless of when the tubes were inserted. If the procedure is bilateral, modifier -50 should be attached.