Part B Insider (Multispecialty) Coding Alert

Question: A surgeon in our group practice wants to report 92504 every time he looks into the patient's ear during the postoperative period, even if the patient does not have a new or different problem. In other words, he wants to report the binocular microscope for routine post-op follow-ups. Is this correct?

Answer: You should not report 92504 (Binocular microscopy [separate diagnostic procedure]) for routine post-op care. If the doctor is simply checking the ear during the global period of a previous procedure, use of the microscope is bundled to the primary procedure. The physician is using the operating microscope like he would use an otoscope to keep track of the healing process. This is not a separately billable service in the post-operative period.

But if your physician uses the binocular microscope for a different problem, such as retrieving a tube that fell out, removing a tube, addressing a new complaint (pain or discharge), there is a chance that the procedure may be billable.

On the other hand, if you happen to be reporting a separate E/M service with 92504. You should maintain separate documentation to stress the distinct nature of the E/M service, and you should also append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code.