Transcript ENT Coding - Silverdale WA Local AAPC

ENT Coding
Presented by Lori Dafoe,
CPC
AGENDA:
•
Review 2013 Coding
Changes specific to ENT
•
Review the sinuses anatomy
•
Discern medical necessity
for various sinus procedures
•
Identify endoscopic sinus
procedures
•
Review the CPT coding and
guidelines
New Codes for 2013 – Allergy Testing
Allergy Testing: CPT codes 95010 and 95015
have been deleted. To report, use the two
new codes below.
•95017 Allergy testing, any combination of
percutaneous (scratch, puncture, prick) and
intracutaneous (intradermal), sequential and
incremental, with venoms, immediate type
reaction, including test interpretation and
report, specify number of tests
•95018 Allergy testing, any combination of
percutaneous (scratch, puncture, prick) and
intracutaneous (intradermal), sequential and
incremental, with drugs or biologicals,
immediate type reaction, including test
interpretation and report, specify number of
tests
New codes for 2013 - Ingestion
Challenge Testing
Ingestion Challenge Testing: CPT 95075 has been deleted
and two new codes have been created to report ingestion
challenge testing.
•95076 Ingestion challenge test (sequential and
incremental ingestion of test items, eg, food, drug or other
substance); initial 120 minutes of testing
•+95079 each additional 60 minutes of testing (List
separately in addition to code for primary procedure)
Additional new codes for 2013
•
2 new codes to report pediatric polysomnography for
children under the age of 6. These services will be
reported using new CPT codes 95782 and 95783.
• 2 new codes to report intraoperative neurophysiology
monitoring in the operating room. This includes new
introductory language in that section of the CPT book as
well. These services will be reported using new CPT codes
95940 and G0453.
Anatomy of the Facial Sinuses




Nasal septum
Ethmoid (right and
left)
Maxillary sinus (right
and left)
Turbinates (concha)



Superior
Middle
Inferior
Upper Respiratory System
Nasal Cavities
Perinasal Sinuses
Medical Necessity
 Nasal
polyps or mucoceles
 Chronic
 Tumors
sinusitis
of the nasal and sinus cavities
 Recurrent
of sinusitis
sinus infections or complications
Nasal Polyps
Medical Necessity

Cerebrospinal fluid leaks

Juvenile Angiofibroma

Nasolacrimal duct obstruction

Choanal Atresia

Chronic sinus headaches
Medical Necessity
 Typically,
patients should have used
medical therapies first, with no significant
signs of improvement, before sinus surgery
is performed.
The Procedure

An endoscope is an instrument made up of a
camera mounted on a flexible tube.

This can be inserted into small anatomical sites,
such as the nose and mouth to visualize the
internal aspects of the body.
Nasal/Sinus Endoscopy Anatomy
The Procedure
 Small
attachments can

Take biopsies of suspicious tissues through
the endoscope

Perform excisions

Or other needed functions
The Procedure
 Endoscopic
Sinus Surgery can be
performed under either
Local anesthesia
or
General anesthesia
The Procedure
 Sometimes
sinus surgery may require
simultaneous repair of the nasal septum
 The
use of packing will depend on the
extent of surgery and physician
preference
Coding Endoscopy
 CPT
31231-31294
 Nasal/Sinus
 Unilateral
Endoscopy
procedures (unless specifically
noted in the code description as bilateral)
Coding Nasal Endoscopies
 Diagnostic
 Procedures
Diagnostic Evaluation
 CPT
31231-31235
 Nasal/sinus
of:




endoscopy for the inspection
Interior nasal cavity
Middle and superior meatus
Turbinates
Spheno-ethmoid recess
Diagnostic Evaluation
 All
diagnostic evaluations include all of
these areas
 Do
NOT code each area separately!
Diagnostic Evaluation



31231 Nasal endoscopy, diagnostic,unilateral
or bilateral (separate procedure)
31233 Nasal/sinus endoscopy,diagnostic with
maxillary sinusoscopy (via inferior meatus or
canine fossa puncture)
31235 Nasal/sinus endscopy, diagnostic with
sphenoid sinusoscopy (via puncture of
spendoidal face or cannulation of ostium)
Identify Access Point
Coding Scenario
A patient, diagnosed with
chronic sinusitis, told his
physician that no medication
has worked and the
inflammation just won’t go
away. The doctor ordered a
diagnostic endoscopy via the
inferior meatus, with a
maxillary sinuscopy.
What is the most accurate
CPT code?
1.) 31231
2.) 31233
3.) 31235



31231 Nasal endoscopy,
diagnostic,unilateral or
bilateral (separate
procedure)
31233 Nasal/sinus
endoscopy,diagnostic with
maxillary sinusoscopy (via
inferior meatus or canine
fossa puncture)
31235 Nasal/sinus
endscopy, diagnostic with
sphenoid sinusoscopy (via
puncture of spendoidal
face or cannulation of
ostium)
Nasal/Sinus Endoscopic
Surgical Procedures
 CPT
31237-31294
 Nasal/sinus
 Surgical


endoscopy, surgical
sinus endoscopy includes:
Sinusotomy (as appropriate)
Diagnostic endoscopy
Coding Functional Endoscopic Sinus
Surgery (FESS)
 31237
Nasal/sinus endoscopy, surgical;
with biopsy, polypectomy or debridement
 31238
Nasal/sinus endoscopy, surgical;
with control of nasal hemorrhage
 CPT
31239 Nasal/sinus endoscopy,
surgical; with dacryocystorhinostomy
 Performed
when the nasolacrimal duct is
blocked and the flow of tears needs to be
restored through the creation of a new
tear duct canal
 31240
Nasal/sinus endoscopy, surgical;
with concha bullosa resection


31254 Nasal/sinus endoscopy, surgical; with
ethmoidectomy, partial (anterior)
31255 Nasal/sinus endoscopy, surgical; with
ethmoidectomy, total (anterior and posterior)
Surgical Endoscopy, cont.
 31256
Nasal/sinus endoscopy, surgical,
with maxillary antrostomy
 31267 Nasal/sinus endoscopy, surgical,
with maxillary antrostomy; with removal of
tissue from maxillary sinus
http://www.youtube.com/watch?v=lrX8gAJfiJs
 31276
Nasal/sinus endoscopy, surgical
with frontal sinus exploration, with or
without removal of tissue from frontal sinus
 31287
Nasal/sinus endoscopy, surgical,
with sphenoidotomy
 31288 Nasal/sinus endoscopy, surgical,
with sphenoidotomy; with removal of
tissue from the sphenoid sinus
Nasal/sinus endoscopy, surgical, with repair
of cerebrospinal fluid leak;
 31290
…ethmoid region
 31291 …sphenoid region
Nasal/sinus endoscopy,
surgical;
 31292
…with medial or inferior orbital wall
decompression
 31293 …with medial orbital wall and
inferior orbital wall decompression
 31294 …with optic nerve decompression
Coding Scenario
The doctor
performed a nasal
endoscopy to control
chronic epistaxis.
What is the correct
code?
1.) 31238
2.) 31254
3.) 31276



31238 Nasal/sinus
endoscopy, surgical; with
control of nasal
hemorrhage
31254 Nasal/sinus
endoscopy, surgical; with
ethmoidectomy, partial
(anterior)
31276 Nasal/sinus
endoscopy, surgical with
frontal sinus exploration,
with or without removal of
tissue from frontal sinus
Balloon Sinus Dilation
 http://sinussurgeryoptions.com/sinusitis-
treatments/balloon-sinus-dilation
Coding Balloon Dilation

31295 Nasal/sinus endoscopy, surgical; with
dilation of maxillary sinus ostium (eg, balloon
dilation), transnasal or via canine fossa (Do not
report 31295 in conjunction with 31233, 31256,
31267 when performed on the same sinus)

31296 with dilation of frontal sinus ostium (eg,
balloon dilation) (Do not report 31296 in
conjunction with 31276 when performed on the
same sinus)

31297 with dilation of sphenoid sinus ostium (eg,
balloon dilation) (Do not report 31297 in
conjunction with 31235, 31287, 31288 when
performed on the same sinus)
CPT 69210 – Removal impacted cerumen,
1 or both ears (separate procedure)
CPT Assistant July 2005, page 14 - Auditory System, 69210 (Q&A)
In collaboration with the American Academy of OtolaryngologyHead and Neck Surgery (AAOHNS), we present the following
discussion which provides some typical coding scenarios with regard
to the appropriate use and application of CPT codes related to ear
wax removal:
1.The patient presents to the office for the removal of “ear wax” by
the nurse via irrigation or lavage.
2.The patient presents to the office for the removal of “ear wax” by
the primary care physician via irrigation or lavage.
3.The patient presents to the office for “ear wax” removal as the
presenting complaint. This is described as impacted cerumen
because it completely covers the eardrum and the patient has
hearing loss. The impacted cerumen is removed by the primary care
physician or otolaryngologist with magnification provided by an
otoscope or operating microscope and instruments such as wax
curettes, forceps, and suction.
Question
Are these procedures appropriately reported with CPT code 69210,
Removal impacted cerumen (separate procedure), one or both
ears?
AMA Comment
A major element in determining whether code 69210 should be
reported is understanding the definition of impacted cerumen. By
definition of the AAO-HNS, “If any one or more of the following are
present, cerumen should be considered ‘impacted’ clinically:
•Visual considerations: Cerumen impairs exam of clinically
significant portions of the external auditory canal, tympanic
membrane, or middle ear condition.
•Qualitative considerations: Extremely hard, dry, irritative cerumen
causing symptoms such as pain, itching, hearing loss, etc.
•Inflammatory considerations: Associated with foul odor, infection,
or dermatitis.
•Quantitative considerations: Obstructive, copious cerumen that
cannot be removed without magnification and multiple
instrumentations requiring physician skills.”
Other issues may also require consideration. Removing wax that is
not impacted does not warrant the reporting of CPT code 69210.
Rather, that work would appropriately be captured by an
evaluation and management (E/M) code regardless of how it is
removed. If, however, the wax is truly impacted, then its removal
should be reported with 69210 if performed by a physician using at
minimum an otoscope and instruments such as wax curettes or, in
the case of many otolaryngologists, with an operating microscope
and suction plus specific ear instruments (eg, cup forceps, right
angles). Accompanying documentation should indicate the time,
effort, and equipment required to provide the service. Add-on code
69990, Microsurgical techniques, requiring use of operating
microscope (List separately in addition to code for primary
procedure), should not be reported if the operating microscope is
used for cerumen removal. In this later instance, however, code
92504, Binocular microscopy (separate diagnostic procedure), may
be reported.
Therefore, based on this information, scenarios 1 and 2 would not be
reported with code 69210. These scenarios would be captured by
the appropriate E/M code. Scenario 3, however, should be reported
with code 69210 because both criteria were met; the patient had
cerumen impaction and the removal required physician work using
at least an otoscope and instrumentation rather than simple lavage.
HCPC - G0268 Removal of impacted cerumen
(one or both ears) by physician on same date of
service as audiologic function testing
•
Must be billed by a physician, physician
assistant, or nurse practitioner. Cannot be
billed by an audiologist!
RACS are here!!
 The
Recovery Audit Contractors are CMS’
hired guns to identify and recoup
improper Medicare payments. They are
paid on a contingency basis…there’s an
incentive for them to “find” mistakes.
RACS of Interest to Otolaryngologists

Untimed Codes - CPT Codes (excluding modifiers KX, and 59) where the
procedure is not defined by a specific timeframe (untimed codes), the
provider should enter a one (1) in the units billed column per date of service.
Example: 92506 - Evaluation of speech, language, voice,
communication, and/or auditory processing

Bronchoscopy Services - CPT Codes 31625, 31628 and 31629 should be billed
with a maximum number of units of one (1) per patient per date of service
(excluding claims with modifier 59) should only be reported with one unit per
date of service

Once in a lifetime procedures - By virtue of the description of the CPT code,
these codes can be performed only once per patient lifetime.
Example: 31360 - Laryngectomy; total, without radical neck dissection

Pediatric codes exceeding age parameters - Newborn/Pediatric CPT codes
being applied/billed for patients which exceed the age limit defined by the
CPT code.
Example: 42820- Tonsillectomy and adenoidectomy; under age 12
Resource/Reference List

MedlinePlus Interactive Tutorials: Sinus Surgery
www.nlm.nih.gov/medlineplus/tutorials/sinussurgery/htm/index.htm

American Rhinologic Society
www.american-rhinologic.org/patientinfo.sinussurgery.phtml

Methodologic Assessment of Studies on Endoscopic
Sinus Surgery
http://archotol.amaassn.org/cgi/content/short/129/11/1230
American Academy of Otolaryngology
www.entnet.org

Questions?