Otolaryngology Coding Alert

Follow the experts’ guidance to getting these claims reimbursed.

CPT^® doesn’t always match up with what your otolaryngologist does, and there are a few easy steps you can take to show carriers what to do with your unlisted- procedure claims.

CPT^® includes unlisted-procedure codes to allow you to report procedures for which there is no specific CPT^® descriptor available. Payment for such claims, however, is not automatic. Your ENT must make a careful effort to document the procedure, and the information you include with your claim can make all the difference.

Tip 1: Don’t Approximate

The only time you should call on an unlisted procedure code (for example, 31299, Unlisted procedure, accessory sinuses) is when no CPT^® code properly describes the procedure your physician performs.

By the same token, however, you shouldn’t select a code that is "close enough" in place of an unlisted-procedure code.

For instance: If the ENT cauterizes olfactory nerve endoscopically via the ethmoid sinus, you should report 31299 because you won’t find an endoscopic code to report this.

Helpful hint: You can find a complete list of unlisted service codes by anatomical/specialty area in the "Guidelines" portion of each CPT^® section.

Roll up your sleeves: Reporting an unlisted-procedure code will require a special letter of explanation to describe the service. But correct coding demands that you use a code that most accurately represents the service the otolaryngologist provides, not a code that is similar but actually represents a different service.

Watch your global: In addition, some payers do not assign any global period to an unlisted-procedure code, so you should query your major payers to determine their global periods for unlisted-procedure codes. For some, you may be able to bill for E/M services postoperatively.

Tip 2: Describe the Procedure in Plain English

Anytime you file a claim using an unlisted-procedure code, you should submit a cover letter of explanation and the full documentation of services.

Here’s why: Insurers consider claims for unlisted procedure codes on a case-by-case basis. If the person making the payment decision can’t understand what the physician did, there’s not much chance that the reimbursement you receive will properly reflect the effort involved. An important part of the coder’s task in preparing the claim is to act as an intermediary between the physician and the claims reviewer, providing a description of the procedure in layman’s terms.

Keep it simple: Avoid or explain medical jargon and difficult terminology. If appropriate, include diagrams or photographs to help describe the procedure you are billing.

Example: Your otolaryngologist performs Thornwaldt/Tornwaldt cyst removal. You should report the unlisted procedure code 42999 (Unlisted procedure, pharynx, adenoids or tonsils). Your documentation should fully describe the procedure, including a letter from the surgeon explaining the need for the nasopharynx excision, and you should also submit a copy of the operative report with the claim.

Tip 3: Compare the Procedure to an Existing Code

If you want to gain appropriate payment for an unlisted procedure claim, you should provide the insurer with an appropriate place to begin. Often, insurers pay for an unlisted procedure claim by reading your procedure description and comparing it to a similar, listed procedure with an established reimbursement value.

Take charge of your claim: Rather than allow the insurer to determine the "next closest" code on which it should base your payment, you should explicitly reference the nearest equivalent listed procedure in your explanatory note.

Why: If you let the insurer choose the comparison code for you, you could end up having to fight it later. For instance, the payer might compare your claim to something valued much lower than the unlisted procedure that your physician performed.

Provide specific details: You should also note how the unlisted procedure differs from the next closest listed procedure.

Answer these questions: Was the unlisted procedure more or less difficult than the comparison procedure? Did it take longer to complete and, if so, by how much (try to provide percentages whenever possible)? Was there a greater risk of complication? Will the patient require a longer recovery and more postoperative attention? Did it require special training, skill or equipment? Any of these factors can make a difference in the reimbursement level you may expect.

Example: CPT^® does not include a code to describe a surgery where the ENT fixes a hole in the roof of the middle ear. He documents a "tympanoplasty with mastoidectomy. During the surgery, I discovered a tegmen tympani cerebrospinal leak, which I repaired by welding it with bipolar cautery. I then reinforced it with a layer of cartilage." Because CPT^® doesn’t include a code to describe this procedure, you should report 69799 (Unlisted procedure, middle ear).

The closest match for comparison would probably be under skull repair 62140 (Cranioplasty for skull defect; up to 5 cm diameter) with a separate code for cartilage graft, or 62146 (Cranioplasty with autograft [includes obtaining bone grafts]; up to 5 cm diameter). This coding combination is not exact, but you’ll want to include a comparison code to help the insurer decide the value of the service. Don’t wait for her to look it up — she might choose a code valued much lower than the unlisted procedure your physician performed.