A EN T.book Page 1 M onday,N ovem ber26,2012 1:22 PM
Coding Companion for ENT/ Allergy/Pulmonology A comprehensive illustrated guide to coding and reimbursement
2014
A EN T.book Page i M onday,N ovem ber26,2012 1:22 PM
Contents Getting Started.....................................................................i Skin/Integumentary .............................................................1 Repair ................................................................................24 Destruction........................................................................59 General Musculoskeletal ....................................................67 Head..................................................................................77 Neck/Thorax....................................................................162 Nose................................................................................167 Accessory Sinuses ............................................................200 Larynx .............................................................................231 Trachea/Bronchi...............................................................264 Lungs/Pleura....................................................................302 Arteries/Veins...................................................................318 Lymph Nodes ..................................................................328 Lips..................................................................................341 Vestibule of Mouth ..........................................................355 Tongue/Floor of Mouth ...................................................369 Dentoalveolar ..................................................................401
CPT only © 2012 American Medical Association. All Rights Reserved.
Coding Companion for ENT/Allergy/Pulmonology
Palate/Uvula ....................................................................415 Salivary Gland .................................................................435 Pharnyx/Adenoids/Tonsils................................................457 Esophagus .......................................................................479 Stomach..........................................................................511 Thyroid............................................................................514 Parathyroid......................................................................525 Nervous...........................................................................529 Ocular .............................................................................536 External Ear .....................................................................540 Middle Ear .......................................................................556 Inner Ear..........................................................................608 Temporal Bone ................................................................616 Operating Microscope.....................................................620 Appendix.........................................................................621 CCI..................................................................................676 Evaluation and Management ...........................................677 Index...............................................................................699
© 2012 OptumInsight, Inc.
Contents
30130-30140
30130 Excision inferior turbinate, partial or complete, any method 30140 Submucous resection inferior turbinate, partial or complete, any method
ICD-9-CM Procedural 21.61 Turbinectomy by diathermy or cryosurgery 21.69 Other turbinectomy
Anesthesia 00160
ICD-9-CM Diagnostic
Explanation
Coding Tips A complete turbinectomy would be performed with caution since excessive hemorrhage can occur from large vessels located in the posterior aspect of the turbinate.
327.23 Obstructive sleep apnea (adult) (pediatric) 327.29 Other organic sleep apnea 375.22 Epiphora due to insufficient drainage 461.3 Acute sphenoidal sinusitis — (Use additional code to identify infectious organism) 461.8 Other acute sinusitis — (Use additional code to identify infectious organism) 470 Deviated nasal septum 472.0 Chronic rhinitis — (Use additional code to identify infectious organism) 472.2 Chronic nasopharyngitis — (Use additional code to identify infectious organism) 473.0 Chronic maxillary sinusitis — (Use additional code to identify infectious organism) 473.1 Chronic frontal sinusitis — (Use additional code to identify infectious organism)
CPT only © 2012 American Medical Association. All Rights Reserved.
Coding Companion for ENT/Allergy/Pulmonology
478.19 Other diseases of nasal cavity and sinuses — (Use additional code to identify infectious organism) 780.51 Insomnia with sleep apnea, unspecified 780.57 Unspecified sleep apnea 786.09 Other dyspnea and respiratory abnormalities 802.0 Nasal bones, closed fracture 802.1 Nasal bones, open fracture 905.0 Late effect of fracture of skull and face bones
CCI Version 18.3
0213T, 0216T, 0228T, 0230T, 12001-12007, 12011-12057, 13100-13153, 30110, 30115, 30200, 30801-30802, 30930, 36000, 36400-36410, 36420-36430, 36440, 36600, 36640, 37202, 43752, 51701-51703, 62310-62319, 64400-64435, 64445-64450, 64479, 64483, 64490, 64493, 64505-64530, 69990, 92502, 93000-93010, 93040-93042, 93318, 94002, 94200, 94250, 94680-94690, 94770, 95812-95816, 95819, 95822, 95829, 95955, 96360, 96365, 96372, 96374-96376, 99148-99149, 99150, J0670, J2001 Also not with 30140: 30130, 30620v Note: These CCI edits are used for Medicare. Other payers may reimburse on codes listed above.
Medicare Edits 30130 30140
Fac Non-Fac RVU RVU FUD 11.54 11.54 90 13.49 13.49 90
Status A A
MUE Modifiers 1 51 50 N/A N/A 30130 1 51 50 N/A N/A 30140 * with documentation Medicare References: None
© 2012 OptumInsight, Inc.
Nose — 173
Nose
In 30130, the physician removes a part or the entire inferior nasal turbinate located on the lateral wall of the nose. The physician places vasoconstrictive drugs on the turbinate to shrink the blood vessels. A mucosal incision is made around the base of the turbinate. The physician fractures the bony turbinate from the lateral nasal wall with a chisel or drill. The turbinate is then excised from the lateral nasal wall. In 30140, the physician removes a part or all of the inferior turbinate bone through a submucous incision. The physician places vasoconstrictive drugs on the turbinate to shrink the blood vessels. A full thickness incision is made over the anterior-inferior surface of the turbinate and continued deep to bone. The physician lifts the mucoperiosteum with an elevator to expose the bony turbinate. A chisel or forceps is used to remove portions of the bony turbinate. In both procedures, electrocautery may control bleeding. The turbinate mucosa is then closed in a single layer. The nasal cavity may be packed with gauze.
160.0 Malignant neoplasm of nasal cavities 170.0 Malignant neoplasm of bones of skull and face, except mandible 197.3 Secondary malignant neoplasm of other respiratory organs 198.5 Secondary malignant neoplasm of bone and bone marrow 212.0 Benign neoplasm of nasal cavities, middle ear, and accessory sinuses 213.0 Benign neoplasm of bones of skull and face 231.8 Carcinoma in situ of other specified parts of respiratory system 235.9 Neoplasm of uncertain behavior of other and unspecified respiratory organs 238.0 Neoplasm of uncertain behavior of bone and articular cartilage 239.1 Neoplasm of unspecified nature of respiratory system 239.2 Neoplasms of unspecified nature of bone, soft tissue, and skin 327.20 Organic sleep apnea, unspecified
473.2 Chronic ethmoidal sinusitis — (Use additional code to identify infectious organism) 473.3 Chronic sphenoidal sinusitis — (Use additional code to identify infectious organism) 473.8 Other chronic sinusitis — (Use additional code to identify infectious organism) 473.9 Unspecified sinusitis (chronic) — (Use additional code to identify infectious organism) 477.9 Allergic rhinitis, cause unspecified — (Use additional code to identify infectious organism) 478.0 Hypertrophy of nasal turbinates
0208T-0209T
0208T Pure tone audiometry (threshold), automated; air only 0209T air and bone
Explanation
0210T-0211T
0210T Speech audiometry threshold, automated; 0211T with speech recognition
Explanation
Automated speech audiometry thresholds are performed using a computer-assisted device. Causes of hearing loss can often be diagnosed through tests using an audiometer. Many causes of hearing loss have characteristic threshold curves unique to that specific diagnosis. In speech audiometry, earphones are placed and the patient is asked to repeat bisyllabic (spondee) words. The softest level at which the patient can correctly repeat 50 percent of the spondee words is called the speech reception threshold. The threshold is recorded for each ear in 0210T. This process occurs in 0211T, in addition to a discrimination test. The word discrimination score is the percentage of spondee words a patient can repeat correctly at a given intensity level above his or her speech reception threshold. This is also measured for each ear.
0212T
0232T
0232T Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed
Explanation
The physician injects platelet rich plasma (PRP) into a targeted site. Harvesting and preparation may also be performed using a variety of techniques. In one, venous blood is drawn from the region of the arm in front of the elbow (antecubital vein) using a butterfly needle. The blood is placed into an appropriate container, centrifuged, and separated into platelet poor plasma (PPP), RBC, and PRP. The PPP is extracted and discarded and the PRP is withdrawn for use. The injection site is marked in order to localize the PRP injection; image guidance may be used. Under sterile conditions, the physician injects the PRP directly into the target area, sometimes using lidocaine or Marcaine. If administered to a joint space, calcium chloride and thrombin may also be added in order to provide a gel matrix for the PRP to adhere to. PRP has many indications, including wound care for the treatment of diabetic and venous stasis ulcers, chronic nonhealing tendon injuries, plantar fasciitis, and augmentation and fusion of bone. Studies suggest that PRP can aid in wound and soft tissue healing and can affect narcotic requirements, bone production (osteogenesis), postoperative blood loss, and inflammation.
0212T Comprehensive audiometry threshold evaluation and speech recognition (0209T, 0211T combined), automated
Explanation
Automated comprehensive audiometry threshold evaluation and speech recognition is performed with the use of a computer-assisted device. Causes CPT only © 2012 American Medical Association. All Rights Reserved.
Coding Companion for ENT/Allergy/Pulmonology
0240T-0241T
0240T Esophageal motility (manometric study of the esophagus and/or gastroesophageal junction) study with interpretation and report; with high resolution esophageal pressure topography 0241T with stimulation or perfusion during high resolution esophageal pressure topography study (eg, stimulant, acid or alkali perfusion) (List separately in addition to code for primary procedure)
Explanation
The physician inserts a tube with sensors (approximately 1 cm apart) into the patient's nose or mouth and down into the stomach to perform an esophageal motility study. In high resolution esophageal pressure topography, the data is collected and displays a representation of the pressure pattern and pressure dynamics throughout the entire esophagus, obtaining information regarding anatomy and pressure gradients, along with the contractile activity. In 0240T, the muscles of the esophagus and/or the gastroesophageal junction, which propel food and water into the stomach, are studied to measure the pressure of the contraction waves and diagnose abnormalities in the esophageal muscle that affect swallowing. The tube is slowly withdrawn and stopped at different points along the esophagus. The patient is directed to swallow a little amount of water at each stopping point and the contraction wave pressure and swallowing action are measured and graphed. Report 0241T in addition to the motility study code when the motility study is combined with stimulation and/or acid or alkali perfusion. The mecholyl provocation test determines the severity of bronchial hypersensitivity, as well as the cause and effectiveness of treatment for bronchospasm. Varied doses of methacholine chloride solution are administered to the patient, following a scheduled protocol of gradually increasing concentration. The patient performs breathing as instructed, and test measurements are taken by spirometry, both before and three minutes after the inhalation challenge of gradually increasing, aerosolized methacholine chloride/diluent solution. A provocative acid perfusion study, also called a Bernstein test, may be administered to attempt to replicate the type of chest pain the patient has been experiencing. This aids in diagnosing the pain as non-cardiac, due to esophageal reflux. Both hydrochloric acid and an alternate saline control solution are infused one after the other via the nasogastric tube, without the patient being aware of the identity of the solution. The symptoms of chest pain are recorded as the patient identifies them.
0243T
0243T Intermittent measurement of wheeze rate for bronchodilator or bronchial-challenge diagnostic evaluation(s), with interpretation and report © 2012 OptumInsight, Inc.
Appendix — 621
Appendix
Pure tone audiometry is performed using a computer-assisted audiometer. Many causes of hearing loss have characteristic threshold curves. In pure tone audiometry, earphones are placed and the patient is asked to respond to tones of different pitches (frequencies) and intensities. The threshold, which is the lowest intensity of tone the patient can hear 50 percent of the time, is recorded for a number of frequencies on each ear. For pure tone signals, which are single-frequency tones produced electronically and transferred through an earphone or bone conduction vibrator, hearing sensitivity is measured separately in each ear. In one method, noise is masked to the non-test ear when it is determined by the computer that masking is necessary. Through touch-screen operation, the patient self-administers the tests while following verbal and on-screen instructions. Report 0208T for automated audiometry including the air conduction mode only and 0209T for automated audiometry including air and bone conduction modes. The air and bone thresholds are compared to differentiate between conductive, sensorineural, or mixed hearing losses.
of hearing loss can often be diagnosed through tests using an audiometer. Many causes of hearing loss have characteristic threshold curves. In comprehensive audiometry, earphones are placed and the patient is asked to respond to tones of different pitches (frequencies) and intensities. The threshold, which is the lowest intensity of tone the patient can hear 50 percent of the time, is recorded for a number of frequencies on each ear. Bone thresholds are obtained in a similar manner except a bone oscillator is used on the mastoid or forehead to conduct the sound instead of tones through earphones. The air and bone thresholds are compared to differentiate between conductive, sensorineural, or mixed hearing losses. With the earphones in place, the patient is also asked to repeat bisyllabic (spondee) words. The softest level at which the patient can correctly repeat 50 percent of the spondee words is called the speech reception threshold. The threshold is recorded for each ear. The word discrimination score is the percentage of spondee words that a patient can repeat correctly at a given intensity level above his or her speech reception threshold. This is also measured for each ear.
A EN T.book Page 677 M onday,N ovem ber26,2012 1:22 PM
Evaluation and Management
Although some of the most commonly used codes by physicians of all specialties, the E/M service codes are among the least understood. These codes, introduced in the 1992 CPT® manual, were designed to increase accuracy and consistency of use in the reporting of levels of non-procedural encounters. This was accomplished by defining the E/M codes based on the degree that certain common elements are addressed or performed and reflected in the medical documentation. The Office of the Inspector General (OIG) Work Plan for physicians consistently lists these codes as an area of continued investigative review. This is primarily because Medicare payments for these services total approximately $32 billion per year and are responsible for close to half of Medicare payments for physician services. The levels of E/M services define the wide variations in skill, effort, and time and are required for preventing and/or diagnosing and treating illness or injury, and promoting optimal health. These codes are intended to represent physician work, and because much of this work involves the amount of training, experience, expertise, and knowledge that a provider may bring to bear on a given patient presentation, the true indications of the level of this work may be difficult to recognize without some explanation. At first glance, selecting an E/M code may appear to be difficult, but the system of coding clinical visits may be mastered once the requirements for code selection are learned and used.
Providers
The qualified health care professional may report services independently or under incident-to guidelines. The professionals within this definition are separate from “clinical staff" and are able to practice independently. CPT defines clinical staff as “a person who works under the supervision of a physician or other qualified health care professional and who is allowed, by law, regulation, and facility policy to perform or assist in the performance of a specified professional service, but who does not individually report that professional service.” Keep in mind that there may be other policies or guidance that can affect who may report a specific service.
Types of E/M Services When approaching E/M, the first choice that a provider must make is what type of code to use. The following tables outline the E/M codes for different levels of care for: • Office or other outpatient services—new patient • Office or other outpatient services—established patient • Hospital observation services—initial care, subsequent, and discharge • Hospital inpatient services—initial care, subsequent, and discharge • Observation or inpatient care (including admission and discharge services) • Consultations—office or other outpatient • Consultations—inpatient The specifics of the code components that determine code selection are listed in the table and discussed in the next section. Before a level of service is decided upon, the correct type of service is identified. Office or other outpatient services are E/M services provided in the physician or other qualified health care provider’s office, the outpatient area, or other ambulatory facility. Until the patient is admitted to a health care facility, he/she is considered to be an outpatient.
The AMA advises coders that while a particular service or procedure may be assigned to a specific section, the service or procedure itself is not limited to use only by that specialty group (see paragraphs 2 and 3 under “Instructions for Use of the CPT Codebook” on page x of the CPT Book). Additionally, the procedures and services listed throughout the book are for use by any qualified physician or other qualified health care professional or entity (e.g., hospitals, laboratories, or home health agencies).
A new patient is a patient who has not received any face-to-face professional services from the physician or other qualified health care provider within the past three years. An established patient is a patient who has received face-to-face professional services from the physician or other qualified health care provider within the past three years. In the case of group practices, if a physician or other qualified health care provider of the exact same specialty or subspecialty has seen the patient within three years, the patient is considered established.
The use of the phrase “physician or other qualified health care professional” (OQHCP) was adopted to identify a health care provider other than a physician. This type of provider is further described in CPT as an individual “qualified by education, training, licensure/regulation (when applicable), and facility privileging (when applicable)” State licensure guidelines determine the scope of practice and a qualified health care professional must practice within these guidelines, even if more restrictive than the CPT guidelines.
If a physician or other qualified health care provider is on call or covering for another physician or other qualified health care provider, the patient’s encounter is classified as it would have been by the physician or other qualified health care provider who is not available. Thus, a locum tenens physician or other qualified health care provider who sees a patient on behalf of the patient’s attending physician or other qualified health care provider may not bill a new patient code unless the attending physician or other qualified health
CPT only © 2012 American Medical Association. All Rights Reserved.
Coding Companion for ENT/Allergy/Pulmonology
© 2012 OptumInsight, Inc.
Evaluation and Management — 677
Evaluation and Management
This section provides an overview of evaluation and management (E/M) services, tables that identify the documentation elements associated with each code, and the federal documentation guidelines with emphasis on the 1997 exam guidelines. This set of guidelines represent the most complete discussion of the elements of the currently accepted versions. The 1997 version identifies both general multi-system physical examinations and single-system examinations, but providers may also use the original 1995 version of the E/M guidelines; both are currently supported by the Centers for Medicare and Medicaid Services (CMS) for audit purposes.
