Otolaryngology Coding Alert

Otolaryngologists have long been urged to document all procedures performed to ensure fair and appropriate payment for their services. It is just as important, however, to use CPT terminology when listing those procedures at the top of an operative report.
 
"The physicians who dictate best not only list all the procedures at the top of the op note, but also use clear, CPT-style language that any coder, experienced or not, can read," says Randa Blackwell, coding and reimbursement specialist for the department of otolaryngology at the University of Maryland in Baltimore.
 
This can be difficult, however, because the words used to describe procedures and conditions in CPT and ICD-9 can differ from the clinical terminology otolaryngologists and other physicians have been trained to use, Blackwell says.
 
Although coders should always read the entire operative report, especially the procedure notes, many do not or cannot do so for a variety of reasons (such as time constraints). In some practices, Blackwell notes, coders do not see the operative report at all.
 
As a result, the otolaryngologist's terminology takes on additional importance. "If the otolaryngologist doesn't dictate in CPT/ICD-9 language, inexperienced coders lose their point of reference. Without CPT language to follow, everybody is lost."
 
This, in turn, can result in difficulty training staff, loss of revenue, audits, delays in getting bills out and denials by carriers.
 
"An inexperienced coder may be confused trying to graft clinical descriptions onto CPT or ICD-9 codes that seem to describe different conditions or services," says Barbara Cobuzzi, MBA, CPC, CPC-H, a coding and reimbursement specialist and president of Cash Flow Solutions, in Lakewood, N.J. "A simple terminology mixup can easily lead to billing errors."

 
In an operative report Cobuzzi reviewed recently, the otolaryngologist listed the following procedures at the top:

Bilateral total endoscopic ethmoidectomy.

Bilateral maxillary antrostomy with tissue removal.

Bilateral sphenoid sinusotomy.

Left frontal sinusotomy.

 
"An experienced coder would assume that all the procedures were performed endoscopically, and would confirm that by looking at the procedure notes in the op report," Cobuzzi says. "But the inexperienced coder, guided mainly by the CPT book, might note that only the first procedure mentions endoscopy."
 
This initial impression could be reinforced by the use of the word "sinusotomy" in the sphenoid and frontal procedures, Cobuzzi notes. "The only codes in CPT that specifically mention "sinusotomy" are open sinus surgery codes. Billers unfamiliar with endoscopic procedures might follow what they see in the book and bill open sphenoid and frontal sinusotomies."
 
Note: CPT includes 14 open surgical codes described as sinusotomies: 31020, 31030, 31032, and 31050-31090.
 
The otolaryngologist should have listed the procedures as follows, Cobuzzi says:

Endoscopic total ethmoidectomy; bilateral (31255-50)

Endoscopic maxillary antrostomy with removal of tissue from maxillary sinus; bilateral (31267-50)

Endoscopic sphenoidotomy; bilateral (31287-50)

Endoscopic frontal sinus exploration (31276).
 
 
"Because the otolaryngologist has used the same language as CPT, finding codes for procedures becomes easier and takes less time, resulting in fewer errors," Cobuzzi says.
 
As always, all documentation, including the body of the operative report, must support the procedures billed. Otolaryngologists have more latitude with the procedure notes than with the dictation at the top of the operative report, but here, too, Cobuzzi recommends using CPT-friendly language whenever possible. In this case, the otolaryngologist could begin the description of each procedure with a phrase that refers to the endoscopic nature of the service, such as "The endoscope was brought into use ..."

Example 2: Myringotomy Versus Tympanostomy

 
The otolaryngologist makes an incision in the eardrum to place a ventilating tube and lists the procedure as "myringotomy with tubes." The novice coder opens CPT and goes to the appropriate section. Two codes describe myringotomies: 69420 (myringotomy including aspiration and/or eustachian tube inflation) and 69421 (... requiring general anesthesia). Both codes also describe tubes (not the tubes that were inserted, of course, but the inexperienced staff person may not know that). Code 69420 is selected incorrectly.
 
In fact, the correct code is 69433 (tympanostomy [requiring insertion of ventilating tube], local or topical anesthesia). An inexperienced staff person, however, might not know that what CPT refers to as "tympanostomy" is, in fact, a myringotomy with tubes.
 
As a result, the term myringotomy with tubes, while clinically appropriate, should be avoided when dictating procedures. Instead, the otolaryngologist should list the procedure as "tympanostomy with insertion of ventilating tube," or something similar.

 
The previous examples illustrate how clinical language that diverges too much from the CPT terminology can complicate billing, leading to incorrect codes and billing delays. But not being specific can also lead to problems.
 
Blackwell cites cases in which an otolaryngologist has performed a planned tracheostomy with flaps but only lists "tracheostomy" in the dictation. As a result, the procedure is coded 31600 (tracheostomy, planned [separate procedure]) instead of 31610 (tracheostomy, fenestration procedure with skin flaps) -- which pays at a much higher rate. According to the Centers for Medicare & Medicaid Services (CMS, formerly HCFA) Physician Fee Schedule, 31600 has 6.26 relative value units (RVUs), whereas 31610 has 19.17 RVUs.
 
In this case, the otolaryngologist would have been able to bill correctly for hundreds of dollars more had the documentation been more descriptive. A simple addition noting that skin flaps were performed, such as "tracheostomy, with skin flaps," could have alerted the coder that this was not an ordinary planned tracheostomy.

 
Using CPT and ICD-9 language not only reduces revenue loss (or inappropriate gain) and speeds billing, it can also decrease denials and protect practices during subsequent audits, Blackwell says.
 
For example, if the otolaryngologist lists a procedure as a "submucous resection" without stating whether the turbinates or the septum was resected, the wrong code may be selected even though the diagnosis codes listed may not support medical necessity for the incorrect procedure.
 
"Just imagine sending such a claim to a commercial carrier to be reviewed by nonclinical personnel who are motivated to look for inappropriate claims," Blackwell says. "The payment process will almost certainly be further delayed, and may be denied altogether if the reviewer determines that the ICD-9 codes submitted don't support the CPT code.
  
"This is why otolaryngologists need to learn to dictate: To make it easier for both coders and carriers to understand what was done," Blackwell continues. And it applies, she says, not only to the top of the operative report, but to the procedure notes as well. "With some op notes, you get to the end and wonder, 'What did they do?' There is a lot of technical information, but no apparent mention of a 'codeable' procedure."
 
Although Blackwell concedes that the number of procedures listed -- and the accuracy of those listings -- also affects billing, she maintains the ill-timed use of clinical jargon in billing can cost practices large sums in lost revenue. "Otolaryngologists need to dictate differently for billing purposes and come to terms with CPT terminology -- which was not created to treat patients, but rather as a tool to help physicians obtain appropriate and correct payment for the services they perform," she says.
 
"Most of the individuals involved in billing and reimbursement [coders in the practice and reviewers with the carriers] do not have clinical backgrounds," Blackwell says. If procedures and conditions are dictated in CPT/ICD-9 language, even the otolaryngologist who does his or her own coding will have an easier time finding the correct codes -- as will any staff employed to check codes before they are billed.