1. science
2. medicine
3. surgery

ENT Coding: Does Your
Nose Know When You
Are Coding It Correctly?
Presented to:
AAPC Annual Meeting
Orlando, Florida
April 16, 2013
Presented by:
Kim Pollock, RN, MBA, CPC
www.karenzupko.com
Kim Pollock, RN, MBA, CPC
Consultant and Speaker
For over thirteen years, Kim Pollock has helped large group practices,
as well as academic and solo practices, improve collections and
efficiency. She is expert at auditing coding and documentation for all
subspecialties of otolaryngology. She knows how to apply
reimbursement principles to ensure otolaryngologists are paid
accurately. She has over thirty years of healthcare experience
working for and with otolaryngologists.
Ms. Pollock understands the complexity of coding and reimbursement
issues specific to otolaryngologists – both from a clinical perspective
and from a payor side. She is an expert in analyzing chart
documentation and in reengineering practices to enhance the reimbursement process.
She presents seminars and workshops for physicians and their staff on behalf of the American
Academy of Otolaryngology-Head and Neck Surgery (AAOHNS), the American Association of
Neurological Surgeons and the American Society of Plastic Surgeons. Ms. Pollock has also
conducted programs for the American Academy of Professional Coders, the North American
Spine Society, the American Neurotology Society and the Congress of Neurological Surgeons.
Based on her previous years of administrative experience, Ms. Pollock has a unique
understanding of the challenges facing academic medicine both clinically and organizationally.
She has served as the Administrator of the Department of Otorhinolaryngology as well as
Associate Vice President of Cancer Programs at the University of Texas Southwestern Medical
Center in Dallas.
Ms. Pollock was the representative for the AAO-HNS on the clinical practice expert paneltechnical group (CPEP-TEG) convened by CMS (formerly HCFA) to redetermine the practice
expense portion of RBRVS. She served two terms on the Board of Directors for the Society of
Otorhinolaryngology and Head-Neck Nurses, Inc. (SOHN) and has served on the Board for the
Ear, Nose and Throat Nursing Foundation.
Ms. Pollock is the recipient of the prestigious Presidential Citation Award from the SOHN as well
as an Honor Award from the AAOHNS.
Ms. Pollock holds a Masters of Business Administration Degree as well as a Bachelors of
Science Degree in Nursing. She is also a certified coder through the AAPC.
KZA Disclaimer
This manual is not intended to provide legal advice to physicians and their staffs. If you have specific questions regarding
the permissibility of your billing or other practices, we recommend that you consult legal counsel directly for assistance in
evaluating any legal, regulatory or compliance issues regarding these matters. In the event that you choose to consult with
outside legal counsel, KZA is available to work with such counsel, as appropriate, to meet your needs.
CPT five digit codes, nomenclature and other data are copyright 2011 American Medical Association. All Rights
Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes
no liability for the data contained herein.
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CPT only © 2012 American Medical Association.
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Modifier 25: Significant, Separately
Identifiable Evaluation and Management
Service by the Same Physician or Other
Qualified Health Care Professional on the
Same Day of the Procedure or Other
Service
CPT Says: It may be necessary to indicate that on the day a procedure or service
identified by a CPT code was performed, the patient's condition required a significant,
separately identifiable E/M service above and beyond the other service provided or
beyond the usual preoperative and postoperative care associated with the procedure
that was performed. A significant, separately identifiable E/M service is defined or
substantiated by documentation that satisfies the relevant criteria for the respective E/M
service to be reported (see Evaluation and Management Services Guidelines for
instructions on determining level of E/M service). The E/M service may be prompted by
the symptom or condition for which the procedure and/or service was provided. As
such, different diagnoses are not required for reporting of the E/M services on the same
date. This circumstance may be reported by adding modifier 25 to the appropriate level
of E/M service.
Note: This modifier is not used to report an E/M service that resulted in a decision to
perform surgery. See modifier 57. For significant, separately identifiable non-E/M
services, see modifier 59.
Tips
Used to indicate an E&M service is significant and separately identifiable on the same
day as a minor procedure. Note, this modifier is not used to report an E&M service
that resulted in decision to perform surgery. (Medicare defines this as a procedure
with a global period of 0 or 10 days).
Attach modifier 25 to the E&M service on same day as minor procedure.
Allows significant, separately identifiable E&M service to be reimbursed on the same
day as a minor procedure.
Different diagnosis not required.
Don’t forget: The global surgical package includes the E&M on the same day of a
minor procedure unless there is “significant, separately identifiable” reason and
documentation for the service. That’s when you append modifier 25 to the E&M code.
Example
Example: New patient E&M for evaluation of hoarseness on same day as a flexible
fiberoptic laryngoscopy (9920x-25 and 31575).
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Modifier 25: Significant, Separately
Identifiable Evaluation and Management
Service by the Same Physician or Other
Qualified Health Care Professional on the
Same Day of the Procedure or Other
Service
The OIG says that modifier 25 is misused and overpayments have resulted. CMS carriers are
auditing – so are private payors.
ALERT: Medicare Part B News (11/5/12) says otolaryngologists billed an E&M visit (99201-99215)
appended with modifier 25 on 42.3% of 2011 Medicare claims. How often did you?
REMEMBER: All procedure codes have an inherent E&M component.
Ask yourself: What have I done that goes “above and beyond” a minimal E&M service that is
included in that procedure code? And, does my documentation support that additional work and
effort?
Scenario
Code(s)
1. New patient, 67 year old female, is seen for hoarseness. In
additional to your usual exam, you also do a flexible fiberoptic
laryngoscopy. You write an E&M note and a separate procedure
note.
2. Established patient you saw two weeks ago returns for
scheduled excision of skin lesions. You write an E&M note and
a separate procedure note.
3. Established patient returns for follow-up of hoarseness after
two weeks of voice rest. Her mirror exam is now within normal
limits. However, she now complains of green drainage from her
nose so you do a nasal endoscopy and diagnosis her with acute
maxillary sinusitis and prescribe an antibiotic. You write an E&M
note and a separate procedure note.
4. Established patient returns for follow-up of hoarseness after
two weeks of voice rest. You do a flexible fiberoptic
laryngoscopy on her and her exam is within normal limits. You
ask her to return prn. You write an E&M note and a separate
procedure note.
5. Established patient returns for follow-up of hoarseness after
two weeks of voice rest. You do a flexible fiberoptic
laryngoscopy on her and her exam is worse. You now prescribe
speech therapy for her and ask her to return in 4 weeks. You
write an E&M note and a separate procedure note.
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CPT only © 2012 American Medical Association.
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Modifier 57: Decision for Surgery
CPT Says: An evaluation and management service that resulted in the initial decision to
perform the surgery may be identified by adding modifier 57 to the appropriate level of
E/M service.
Tips
Used to reflect a surgery decision-making E&M service was performed on the day
before or the day of a major procedure. (Medicare defines this as a procedure
with a global period of 90 days.)
Append modifier 57 to the E&M service same day or day before major, or
unplanned, procedure.
Allows payment for the E&M as well as the procedure. This typically is the
decision making E&M for an emergent or unplanned major procedure.
Different diagnosis not required.
Do not use modifier 57 on an E&M code to report a routine pre-op visit or an H&P
on the day of the elective procedure.
Examples
You are asked to see a non-Medicare patient in the emergency room at the
request of Dr. ER to evaluate a deep neck abscess. You perform the consultation
service (9924x-57) and take the patient to the operating room for I&D (21501).
You admit a Medicare patient from your office to the hospital to treat a deep neck
abscess with IV antibiotics and subsequently see the patient in the hospital on the
same day to perform the admission H&P (9922x-57, AI). The abscess requires
I&D the next day (21501).
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Office Endoscopy
Nasal Endoscopy
31231 Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure)
Evaluation of the nasal passages
Tip:
The parenthetical statement “(separate procedure)” means this procedure may
be billed when it is a completely separate procedure from others performed at
the same operative session. Do not report a “separate procedure” when
included in a more extensive CPT code (e.g., 31231 is included in all surgical
endoscopic sinus surgery codes such as 31255).
Diagnostic Sinus Endoscopy
31233 Nasal/sinus endoscopy, diagnostic with maxillary sinusoscopy (via inferior
meatus or canine fossa puncture)
31235 Nasal/sinus endoscopy, diagnostic with sphenoid sinusoscopy (via puncture of
sphenoidal face or cannulation of ostium)
CPT 31233 and 31235 require a puncture or trocar cannulation prior to placing
the scope into the sinus.
Do not report 31233 or 31235 for diagnostic sinus endoscopy performed via an
existing and patent opening into the maxillary or sphenoid sinus is incorrect.
These procedures are typically performed in the operating room.
Nasopharyngoscopy
92511 Nasopharyngoscopy with endoscope (separate procedure)
Evaluation of the nose, nasopharynx and pharynx
Flexible Fiberoptic Laryngoscopy (FFL)
31575 Laryngoscopy, flexible fiberoptic; diagnostic
Evaluation of the nose, nasopharynx, pharynx and larynx
Do not also report 31231 for nasal endoscopy performed at the same time
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Office Endoscopy
Transnasal Esophagoscopy
43200 Esophagoscopy, rigid or flexible; diagnostic, with or without collection of
specimen(s) by brushing or washing (separate procedure)
Requires evaluation of the esophagus down to the gastro-esophageal (GE)
junction.
Append modifier 52 (reduced services) if evaluation down to the gastroesophageal junction is not performed
Tracheobronchoscopy
31615 Tracheobronchoscopy through established tracheostomy incision
Use 31615 for full bronchoscopy via tracheostomy.
Append modifier 52 (reduced services) if only tracheoscopy, without full
bronchoscopy, was performed.
See 31525 code series (direct laryngoscopy) for tracheoscopy (without full
bronchial exam) when not performed via tracheostomy.
FAQ
Q: Can I bill for a mirror exam using the indirect laryngoscopy code (31505)? I do
one on almost all my new patient visits.
A: No, this is part of an ENT exam and not separately reported.
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Office Endoscopy
31237 Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement (separate
procedure)
Example: Patient returns two days after endoscopic sinus surgery and septoplasty. The
physician performs bilateral endoscopic sinus debridement.
ICD-9-CM Code(s):
1. 473.2 Chronic Ethmoid Sinusitis
2. 473.0 Chronic Maxillary Sinusitis
CPT Code/
Modifier(s)
Description
31237-79
31237-50, 79
Endoscopy, unilateral
Endoscopy, unilateral
ICD-9-CM
Code
1, 2
1, 2
8-NF
Reported
Expected RVUNF Paid
9.88
9.88
9.88
4.94
19.76
14.82
OR
31237-50, 79
Endoscopy, bilateral
1, 2
Debridement: The removal of foreign material, and devitalized, or infected tissue from or
adjacent to a traumatic or infected lesion until surrounding healthy tissue is seen.
Use CPT 31237 to report post-operative endoscopic debridements performed outside
the 0-day global surgery period following FESS.
Do not use CPT 31237 for non-endoscopic nasal sinus debridements.
CPT Assistant, December 2011
Although two to three debridements in the first 30 days is typical for the majority of
patients, once a week may be an appropriate frequency for postoperative debridement in
select patients with difficult problems. However, the frequency and length of time for
which debridement is medically necessary will vary from case to case and must be
individualized, a conclusion, which multiple studies analyzing debridement outcomes
have acknowledged.
While their limited use will likely suffice in the majority of cases, there are situations in
which a patient may require more frequent, very long-term debridements. Clinically,
these include but are not limited to:
o Persistent crusting within the surgical bed,
o Adhesion formation noted upon examination,
o More extensive surgery (e.g., complex frontal sinusotomies, neoplasm
resections),
o Underlying immunologic disorders,
o Diffuse polyposis,
o Revision FESS, mucociliary disorders,
o Allergic fungal sinusitis,
o And postoperative complications (e.g., visual loss, cerebrospinal fluid leak).
Tip:
Do not report an E&M code with 31237 unless there is also a significant, separately
identifiable service provided (e.g., a different diagnosis such as acute otitis media).
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Tonsillectomy/Adenoidectomy
Tonsillectomy
Alone
42825 < age 12
42826 ≥ age 12
With
Adenoidectomy
42820 < age 12
42821 ≥ age 12
Adenoidectomy
Primary (first one)
42830 < age 12
42831 ≥ age 12
Secondary (subsequent)
42835 < age 12
42836 ≥ age 12
Tips:
All codes have a 90-day global period, per CMS
Biopsy(ies) obtained of the nasopharyngeal tissue in conjunction with a T&A is not
separately reported. May separately bill for the biopsy if only a tonsillectomy is
performed.
CMS says: Do not bill for treatment of complications in the global period unless there
is a return to the OR (then append billed CPT code with modifier 78).
Unplanned overnight stay on the day of procedure is not separately reported if reason
is due to surgery (e.g., pain, dehydration).
Unplanned re-admissions (e.g., dehydration) may be separately reported with modifier
24.
What about post-op tonsillectomy bleeds?
o In-office treatment – Medicare says do not bill; check with other payors for
policy
o In ER – Medicare says do not bill; check with other payors for policy
o Return to the OR – bill with modifier 78
 42960
Control oropharyngeal hemorrhage, primary or secondary
(e.g., post-tonsillectomy); simple
 42961
complicated, requiring hospitalization
 42962
with secondary surgical intervention (e.g., suture ligation
of bleeders)
 Primary = within 24 hrs after surgery, secondary = 24 hours to two
weeks later
 42960 and 42961 involve clot evacuation, applying pressure with
sponges, electrocautery, application of vasoconstrictor solutions such
as tannic acid, silver nitrate and epinephrine.
 42962 involves surgical intervention (e.g., suture ligation of bleeding
vessels)
Refer to CPT 42970-42972 for postop adenoidectomy bleed control in the OR and
append modifier 78.
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Turbinate Procedures
CPT
Code
Description
Unilateral/ Bilateral
30801 Ablation, soft tissue of inferior turbinates,
unilateral or bilateral, any method (e.g.,
electrocautery, radiofrequency ablation, or
tissue volume reduction); superficial
Unilateral or Bilateral
(no modifier 50)
30802
Unilateral or Bilateral
(no modifier 50)
intramural (i.e., submucosal)
30930 Fracture nasal inferior turbinate(s),
therapeutic
Unilateral or Bilateral
(no modifier 50)
30130 Excision inferior turbinate, partial or
complete, any method
Unilateral
(modifier 50 acceptable)
30140 Submucous resection inferior turbinate,
partial or complete, any method
Unilateral
(modifier 50 acceptable)
Coding Tips:
Do not report 30801 in conjunction with 30802
For 30140: The documentation should indicate the mucosa was entered/incised
and preserved and tissue and/or bone was removed. A statement such as
“excised the turbinate(s)” is not sufficient to accurately take into account the
submucous resection of the inferior turbinate(s), and would not support 30140.
Do not report 30140-52 for “turbinate reduction” – refer to 30801 or 30802.
Do not report 30801, 30802, and 30930 in conjunction with 30130 or 30140.
Performing middle turbinate surgery to “gain access” to the sinuses is not
separately reported.
It may be necessary to apend modifier 59 to 30802 when reported with 30930 to
show separate procedures were performed.
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Endoscopic Sinus Surgery
CPT
Code
31240
31254
31255
31256
31267
31276
31287
31288
Description
Nasal/sinus endoscopy, surgical; with concha bullosa resection
Nasal/sinus endoscopy, surgical; with ethmoidectomy, partial (anterior)
with ethmoidectomy, total (anterior and posterior)
Nasal/sinus endoscopy, surgical with maxillary antrostomy;
with removal of tissue from maxillary sinus
Nasal/sinus endoscopy, surgical with frontal sinus exploration, with or without removal of
tissue from frontal sinus
Nasal/sinus endoscopy, surgical with sphenoidotomy;
with removal of tissue from the sphenoid sinus
Remember:
May separately report 31240 for endoscopic resection of concha bullosa when appropriately
documented (e.g., pre-op diagnosis, CT scan findings). Otherwise, middle turbinate surgery is
included in the endoscopic sinus surgery codes.
“Removal of tissue” for 31267 and 31288 = polyps, mucocele, fungus ball; not – “debris,” “contents,”
mucous or pus.
Do not report 31254 – 31288 with the balloon dilation codes (31295-31297) for procedures on the
same sinus. Report the above codes when tissue and/or bone is removed.
All of the above codes include removal of nasal polyps from the same side at the same operative
session; do not separately report 31237 (or 30110, 30115).
Stereotactic Computer Assisted
Navigation (SCAN)
CPT
Code
31295
31296
31297
Description
Nasal/sinus endoscopy, surgical; with dilation of maxillary sinus ostium (eg, balloon
dilation), transnasal or via canine fossa
with dilation of frontal sinus ostium (eg, balloon dilation)
with dilation of sphenoid sinus ostium (eg, balloon dilation)
Coding Tips:
Report above code when tissue is displaced. If tissue and/or bone is removed, then see codes
31254-31288. If tissue is both displaced and removed, then see codes 31254-31288.
There is no current balloon technology for use in the ethmoid sinus; therefore, there is no ethmoid
code.
Beware: Some payors consider this “experimental” or “investigational” and will not pay. This service
may possibly be billed to the patient.
Codes include fluoroscopy – do not separately report 76000.
Do not report 31295 in conjunction with 31233, 31256, or 31267 when performed on the same sinus.
Do not report 31296 in conjunction with 31276 when performed on the same sinus.
Do not report 31297 in conjunction with 31235, 31287, or 31288 when performed on the same sinus.
Non-facility RVUs are high due to the practice expense incurred associated with purchasing the
equipment. Although, the NF RVUs did decrease by almost half in 2012 (compared to 2011).
Do not separately report a lavage code (31000, 31002) with the above codes.
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Stereotactic Computer Assisted
Navigation (SCAN)
+61782 Stereotactic computer assisted volumetric (navigational) procedure, cranial,
extradural (List separately in addition to code for primary procedure)
AAO-HNS Policy on Intra-Operative Use of Computer Aided Surgery
The American Academy of Otolaryngology – Head and Neck Surgery endorses the
intraoperative use of computer-aided surgery in appropriately select cases to assist the
surgeon in clarifying complex anatomy during sinus and skull base surgery. There is
sufficient expert consensus opinion and literature evidence base to support this position.
This technology is used at the discretion of the operating surgeon and is not
experimental or investigational. These appropriate, specialty specific, and surgically
indicated procedural services should be reimbursed whether used by neurosurgeons or
other qualified physicians regardless of the specialty. Examples of indications in which
use of computer-aided surgery may be deemed appropriate include:
1) Revision sinus surgery.
2) Distorted sinus anatomy of development, postoperative, or traumatic origin.
3) Extensive sino-nasal polyposis.
4) Pathology involving the frontal, posterior ethmoid and sphenoid sinuses.
5) Disease abutting the skull base, orbit, optic nerve and carotid artery.
6) CSF rhinorrhea or conditions where there is a skull base defect.
7) Benign and malignant sino-nasal neoplasms.
Documentation Requirements per American Rhinologic Society
Include in the “Indications for Surgery” paragraph the medical necessity of need for
stereotactic guidance.
Document pre-op surgical planning including downloading and verifying images.
Document registration of data.
Document instrument calibration.
Document Target Registration Error (TRE).
Document anatomic localization and confirmation during surgery.
Include “endoscopic” approach and intra-operative computer findings.
Tip:
Be sure to document the need for use of navigational assistance— this provides
the medical necessity for the additional charge.
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Endoscopic Sinus Surgery Cases
1. Procedure: Bilateral endoscopic maxillary antrostomies with tissue removal
Detail: …endoscope was used..the middle turbinate was medialized….the uncinate
was noted to be without any polypoid changes…a right-angle curette was utilized to
forward-fracture the uncinate and the microdebrider was utilized to take down the
uncinate…this revealed evidence of polypoid changes at the maxillary sinus ostium
causing occlusion of the ostium on the left….microdebrider was utilized to remove
the polypoid changes and a micropunch was utilized to widen the maxillary sinus
ostium on the left…..same procedure performed on right side….
Choose the correct code combination: ___________
A
B
31267
31256
31267-50
31256-50
2. Bilateral endoscopic total ethmoidectomies
Bilateral endoscopic sphenoidotomies
Bilateral endoscopic maxillary antrostomies with removal of polyps from within the
maxillary sinuses
Use of stereotactic navigation and image-guided system
Choose the correct code combination: ________________
A
B
31255
31255-50
31255-50
31267-50
31267-51
31287-50
31267-50
61782
31287-51
31287-50
61782
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Endoscopic Sinus Surgery Cases
3. Septoplasty, bilateral inferior turbinate submucous resections, bilateral endoscopic
nasal polypectomies, bilateral endoscopic maxillary antrostomies and bilateral
endoscopic anterior ethmoidectomies.
Choose the correct code combination: ___________
A
B
30520
30520
30140-51
30140-51
30140-50
30140-50
31254-51
31254-51
31254-50
31254-50
31256-51
31256-51
31256-50
31256-50
31237-59
31237-50, 59
4. Operative note reads: Balloon sinus ostia catheterization and dilation of both
maxillary sinuses under fluoroscopy. There is no documentation of removal of bone
and mucosa.
Choose the correct code combination: ___________
A
B
31256
31295
31256-50
31295-50
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Endoscopic Sinus Surgery Cases
5. Operative note reads: Bilateral endoscopic maxillary antrostomies using forceps and
microdebrider for removal of bone and mucosa as well as balloon catheter sinus ostia
dilation technology under fluoroscopy.
Choose the correct code combination: ___________
A
B
31256
31256
31256-50
31256-50
31295-51
31295-50
6. Bilateral endoscopic total ethmoidectomies, bilateral endoscopic maxillary antrostomies,
bilateral outfracture and submucous resection of inferior turbinates, septoplasty
Choose the correct code combination: __________
A
B
30520
30520
30140-51
30140-51
30140-50
30140-50
31255-51
31255-51
31255-50
31255-50
31256-51
31256-51
31256-50
31256-50
30930-59
30930-50, 59
7. Septoplasty, endoscopic sphenoidotomy, and approach for neurosurgeon to remove a
pituitary tumor.
Choose the correct code combination: __________
A
B
30250
62165-62
31287
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Snoring/Sleep Apnea Procedures
In addition to the septoplasty, tonsillectomy and turbinate codes, the most common CPT
codes used for insurance billed procedures include:
CPT
Description
Code
21199 Osteotomy, mandible, segmental; with genioglossus
advancement
21685 Hyoid myotomy and suspension
41512 Tongue base suspension, permanent suture technique
41530 Submucosal ablation of the tongue base, radiofrequency,
one or more sites, per session
42145 Palatopharyngoplasty (e.g., uvulopalatopharyngoplasty,
uvulopharyngoplasty)
Global
Period
90
90
90
10
90
Note: Many payors do not reimburse for 41512 or 41530. Obtain written prior
authorization.
RVU-NF for 41530 are high because the physician assumes the practice
expense for performing the procedure (e.g., radiofrequency probe).
Don’t forget to use separate diagnoses for these procedures such as turbinate
hypertrophy, tonsillar hypertrophy, deviated septum, etc.
Remember: Use an unlisted code (42299) for a LAUP (laser-assisted
uvulopalatoplasty).
Example
Procedures performed: Septoplasty, Bilateral submucosal inferior turbinate reduction
using radiofrequency, Coblation of the tongue base, Tonsillectomy,
Uvulopalatopharyngoplasty
Choose the correct code combination: ___________
A
B
42145
30520-51
41530-51
42826-51
30140-52, 51
30140-52, 50
42145
30520-51
41530-51
42826-59
30802-51
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Ear Procedures
TYMPANOSTOMY TUBE PLACEMENT
Type of Anesthesia
69433
Local or topical
69436
General
Codes may be reported bilaterally with modifier 50.
CMS says: 10-day global period.
Do not separately bill myringotomy – it’s included in 69433/69436.
Tube placement is included in a larger primary procedure performed on the same
ear (e.g., tympanoplasty).
Includes use of the microscope; do not separately report 92504 or 69990.
Remember to use correct billing format as required by payor:
o 69436-50 on one line versus 69436 and 69436-50 on two lines
TYMPANOSTOMY TUBE REMOVAL
69424 - Ventilating tube removal requiring general anesthesia
Code has a 0-day postoperative global period
May be reported with modifier 50 if performed bilaterally
Tube removed without general anesthesia may be reported with an E&M code,
92504 (binocular microscopy), or other appropriate code. It is not a “foreign body
removal” (69200-69205).
Tube removal with another procedure on the same ear (e.g., perforation repair,
tympanoplasty, mastoidectomy) is included in the larger primary procedure and
not separately reported.
Scenario: The surgeon who originally placed the tympanostomy (ventilating)
tubes brings the patient to the outpatient facility. Under general anesthesia and
utilizing an operating microscope, the surgeon creates a relaxing incision. The
surgeon removes the tube with surrounding granulation tissue, thus creating an
optimal situation for closure of the perforation in which the tube was situated.
Monitoring of the ear in the office setting revealed the perforation to have closed
within several weeks’ time.
Scenario: Removal of a tympanostomy tube from the external auditory canal. Is
this a “foreign body removal”?
No, it is not a foreign body removal. This is part of your E&M code when
performed in your office; you may report 92504 if you use the microscope. If
performed in the operating room, consider using 92502 (Otolaryngologic
examination under general anesthesia). Append modifier 52 (reduced services)
if a full ENT exam under anesthesia is not performed.
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Ear Procedures
FOREIGN BODY REMOVAL
69200 Removal foreign body from external auditory canal; without general anesthesia
69205
with general anesthesia
Use for removal of items such as beads, insects, ear candling wax, etc.; do not
use for removal of a tympanostomy tube.
Includes use of the microscope; do not separately report 92504 or 69990.
TYMPANIC MEMBRANE REPAIR
CPT Code
Description
69610 Tympanic membrane
repair, with or without
site preparation of
perforation for
closure, with or
without patch
69620 Myringoplasty
(surgery confined to
drumhead and donor
area)
Comments
May be reported with modifier 50
CMS says: 10-day global period
Example: Freshening the edges of the
perforated area of the tympanic
membrane, paper patch graft
May be reported with modifier 50
CMS says: 90-day global period
A fat graft plug or a temporalis fascia
graft may be placed medially to the
eardrum
Includes the harvesting of a donor graft
when performed (do not separately
report code such as 20926).
The middle ear is not entered in this
procedure
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Ear Procedures
TYMPANOPLASTY (Initial or Revision)
CPT
Description
Code
69631 Tympanoplasty without mastoidectomy (including canaloplasty,
atticotomy and/or middle ear surgery), initial or revision; without ossicular
chain reconstruction
69632
with ossicular chain reconstruction (e.g., post fenestration)
69633
with ossicular chain reconstruction and synthetic prosthesis (e.g.,
partial ossicular replacement prosthesis [PORP], total ossicular
replacement prosthesis [TORP])
Tips from CPT Assistant, August 2008:
May be done transcanal or via a postauricular incision
Graft harvest through a separate skin incision for repair/reconstruction may be
reported separately (e.g., 20926).
Codes require entry and inspection of the middle ear.
Middle ear exploration (69440), exploratory tympanotomy, tube placement (69436),
or membrane repair (69610) are not separately reportable.
Scenario: I’m working on an appeal for a denial we received in 2012. Can you please
help?
We billed 69631 (transcanal tympanoplasty) and 20926 for harvesting a temporalis
fascia graft. We also billed 69990, 95920 x 2 units (for 2 hours of intraoperative
monitoring) and 95927 (somatosensory evoked potential study of the head and neck).
We got paid on 69631 and 20926 but denied on the rest of the codes. Please help!
Action: The intraoperative monitoring codes, 95920 and 95927, should not have been
billed. Write off these charges. Intraoperative nerve monitoring was not separately
billable for the surgeon in 2012 nor is it billable for the surgeon in 2013. CPT 69990
may or may not be reimbursed depending on payer policy; Medicare will not reimburse
69990 when billed with the auditory system codes.
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Neck Dissection
Neck Dissection CPT Codes
38700 Suprahyoid lymphadenectomy
38720 Cervical lymphadenectomy (complete)
38724 Cervical lymphadenectomy (modified radical neck dissection)
Coding Tips
38700 = suprahyoid; involves removal of level I nodes only (CPT Assistant,
August 2010).
38724 = modified radical or selective neck dissection (removal of lymph nodes in
levels I - V; involves the removal of all lymph nodes routinely removed by radical
neck dissection, while preserving the internal jugular vein, the spinal accessory
nerve and/or the sternocleidomastoid muscle. Involves removal of more than
level I nodes.
38720 = complete or radical; includes all five regions of the neck. In addition, the
internal jugular vein, the spinal accessory nerve, and the sternocleidomastoid
muscle are removed.
It is appropriate to report a neck dissection code (e.g., 38724) with a direct
laryngoscopy (e.g., 31525) if both are performed. The laryngoscopy is a
separate diagnostic service and is not included in the neck dissection codes.
Be sure to document lymph node removal. If the procedure is performed after
radiation therapy has been delivered then be sure to document tissue removal.
ALERT: There is no CPT code for only a “neck dissection”!
Do not use a primary procedure code if it includes a radical neck dissection and
you’ve done a modified radical neck dissection. Rather, report the primary code
that does not include a neck dissection and separately report the modified radical
neck dissection code(s).
o Example: Laryngectomy with bilateral modified radical neck dissections
Do
Don’t
31360 Laryngectomy w/o RND
38724-59 MRND
38724-50, 59 MRND
31365
Laryngectomy w/RND
38724-59 MRND
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