ENT Coding

1. ENT Coding Presented by Lori Dafoe, CPC

2. 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

3. 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

4. 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)

5. 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.

6. Anatomy of the Facial Sinuses • Nasal septum • Ethmoid (right and left) • Maxillary sinus (right and left) • Turbinates (concha) • Superior • Middle • Inferior

7. Upper Respiratory System

8. Nasal Cavities

9. Perinasal Sinuses

10. Medical Necessity • Nasal polyps or mucoceles • Chronic sinusitis • Tumors of the nasal and sinus cavities • Recurrent sinus infections or complications of sinusitis

11. Nasal Polyps

12. Medical Necessity • Cerebrospinal fluid leaks • Juvenile Angiofibroma • Nasolacrimal duct obstruction • Choanal Atresia • Chronic sinus headaches

13. Medical Necessity • Typically, patients should have used medical therapies first, with no significant signs of improvement, before sinus surgery is performed.

14. 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.

15. Nasal/Sinus Endoscopy - Anatomy

16. The Procedure • Small attachments can • Take biopsies of suspicious tissues through the endoscope • Perform excisions • Or other needed functions

17. The Procedure • Endoscopic Sinus Surgery can be performed under either Local anesthesia or General anesthesia

18. 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

19. Coding Endoscopy • CPT 31231-31294 • Nasal/Sinus Endoscopy • Unilateral procedures (unless specifically noted in the code description as bilateral)

20. Coding Nasal Endoscopies • Diagnostic • Procedures

21. Diagnostic Evaluation • CPT 31231-31235 • Nasal/sinus endoscopy for the inspection of: • Interior nasal cavity • Middle and superior meatus • Turbinates • Spheno-ethmoid recess

22. Diagnostic Evaluation • All diagnostic evaluations include all of these areas • Do NOT code each area separately!

23. Diagnostic Evaluation • 31231 Nasal endoscopy, diagnostic,unilateral or bilateral (separate procedure) • 31233 Nasal/sinus endoscopy,diagnosticwith 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)

24. Identify Access Point

25. 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)

26. Nasal/Sinus Endoscopic Surgical Procedures • CPT 31237-31294 • Nasal/sinus endoscopy, surgical • Surgical sinus endoscopy includes: • Sinusotomy (as appropriate) • Diagnostic endoscopy

27. Coding Functional Endoscopic Sinus Surgery (FESS) • 31237 Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement

28. 31238 Nasal/sinus endoscopy, surgical; with control of nasal hemorrhage

29. 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

30. 31240 Nasal/sinus endoscopy, surgical; with concha bullosa resection

31. 31254 Nasal/sinus endoscopy, surgical; with ethmoidectomy, partial (anterior) • 31255 Nasal/sinus endoscopy, surgical; with ethmoidectomy, total (anterior and posterior)

32. 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

33. 31276 Nasal/sinus endoscopy, surgical with frontal sinus exploration, with or without removal of tissue from frontal sinus

34. 31287 Nasal/sinus endoscopy, surgical, with sphenoidotomy • 31288 Nasal/sinus endoscopy, surgical, with sphenoidotomy; with removal of tissue from the sphenoid sinus

35. Nasal/sinus endoscopy, surgical, with repair of cerebrospinal fluid leak; • 31290 …ethmoid region • 31291 …sphenoid region

36. 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

37. 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

38. Balloon Sinus Dilation • http://sinussurgeryoptions.com/sinusitis-treatments/balloon-sinus-dilation

39. 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)

40. CPT 69210 – Removal impacted cerumen, 1 or both ears (separate procedure)

41. CPT Assistant July 2005, page 14 - Auditory System, 69210 (Q&A) In collaboration with the American Academy of Otolaryngology-Head 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.

42. 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, irritativecerumen 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.”

43. 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.

44. 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.

45. 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!

46. 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.

47. 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

48. 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 • MethodologicAssessment of Studies on Endoscopic Sinus Surgery http://archotol.amaassn.org/cgi/content/short/129/11/1230 • American Academy of Otolaryngology www.entnet.org

49. Questions?