Otolaryngology Coding Alert

Failing to bill commercial payers for 69990 when performed in addition to middle and inner ear surgeries will sacrifice more than $128 for your ENT's work.

Medicare does not allow +69990 (Microsurgical techniques, requiring use of operating microscope [list separately in addition to code for primary procedure]) with middle and inner ear surgeries. Therefore, when an otolaryngologist performs microdissection during complicated ear surgeries, many otolaryngologists and otolaryngology coders question if they should report 69990. Using 69990 as an add-on when doing 69500 (excision) and 69600 (repair) series procedures seems appropriate, writes David G. Bailey, MD, an ENT in Marion, Ohio.

The National Correct Coding Initiative (NCCI) bundles microsurgical techniques, requiring use of operating microscope (OM) into ear surgery codes (69501-69554, middle ear excision; 69601-69676, middle ear repair; and 69905-69915, inner ear excision). "This edit is a budgetary one and does not have a clinical basis," 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. Thus, for third-party payers that do follow NCCI, you may report the microsurgery add-on code in addition to complex ear surgery, she says.

The NCCI edits apply to Medicare and Medicaid, but because the bundle does not have clinical support, in this case you should use different billing methods to your advantage. "Many coders forget that you do not have to bill all insurers the same way," says Andrew Borden, CCS-P, CPC, CMA, reimbursement manager in the department of otolaryngology and communication sciences at Medical College of Wisconsin in Milwaukee.

Medicare uses NCCI edits to explain what it thinks is appropriate coding. "Although employing Medicare's policies across the board might seem easier than keeping track of multiple guidelines, using Medicare's rule for all insurers may financially hurt your business," Borden says. Therefore, with 69990 and ear surgeries, your bottom line will benefit from following individual payer rules.

Report 69990 Combo to Private Payers

For non-Medicare insurers, you should not include 69990 in the ear surgery codes. According to CPT, you may use 69990 with middle or inner ear surgery, says Karen Strickler, assistant manager/billing manager at Southeastern ENT & Sinus Center in Greensboro, N.C.

"CPT very plainly lists the procedures that have 69990 as an inclusive component," Strickler says. The list does not include middle and inner ear surgeries, she adds. Therefore, you may report 69990 in addition to ear surgeries, such as 69501 (Transmastoid antrotomy [simple mastoidectomy]), to commercial payers if the surgeon uses microsurgery techniques.

 

On the other hand, Medicare and Medicaid believe that microdissection requiring OM use is inherent in the ear surgery codes. Thus, you should not separately report 69990 to government carriers.

In fact, repeatedly billing disallowed combinations to Medicare is considered fraud, Borden warns.

Fear of committing fraud may steer doctors away from appropriately billing the microdissection/ear surgery combination. For instance, Strickler says that despite pointing out to her otolaryngologists that use of the OM is not inherent in the ear surgery codes, her doctors are still reluctant to use 69990.

But, you should bill commercial carriers for the microdissection add-on code (69990) until CPT says it's not permissible, Borden says. In fact, Borden and Strickler say that a majority of their private payers are covering the code.

To encourage your otolaryngologists to report 69990, ask them if they think the relative value units (RVUs) for the ear surgery codes include using the OM. "When the CPT editorial advisory board (EAB) in the 1980s or 1990s created the microscope and ear surgery codes, did they assume all doctors used the microscope in every ear surgery case and thus built the 69990 RVUs into the ear surgery codes?" Borden asks.

If the EAB considered 69990 an inherent part of ear surgery, they should have included the ear surgery codes in the bundled list following 69990 in the CPT manual, Borden says. But, they didn't. Therefore, the ear surgery codes, according to CPT, do not include the RVUs for using the OM.

Because Medicare and CPT differ on 69990's inclusion in ear surgery codes, you should not fight every non-Medicare insurer denial. But you should appeal as many as you can, Borden says. "Send a copy of CPT's notes showing the codes associated with 69990 and pointing out that the ear surgery code is not on the list." Therefore, you are separately billing for microdissection using the OM.

Make sure that the otolaryngologist documented the need for using the microscope, he adds. For instance, documentation might state: "The physician needed to use OM to critically remove the bony part during surgery." Remember that 69990 now represents the physician using microsurgical techniques, not just the presence of the OM in the operating room. In 2002, CPT changed 69990's definition from "use of operating microscope " to "microsurgical techniques, requiring use of operating microscope." The change clarifies that the AMA editorial advisory board intends 69990 to pay for using microdissection and microsurgical techniques

In fact, correctly documenting use of the OM will help anytime you report 69990. It may be helpful if ENTs dictate a statement, such as "Used surgical microscope for microdissection of ______________," Strickler says. If the surgeon can fill in the blank with a code that is not listed in the CPT manual as inclusive to 69990, you should charge third-party payers for the code, she says.