Top 10 Errors in ENT Coding and Documentation

Candice Fenildo, CPC, CPMA, CPB, CPC-I, CRHC, CENTC, AAPC Fellow

Agenda • Surgical Guidelines • Nasal Fractures • When to “add on” those grafts• When is an E/M code justified with procedures • Multiple Scopes in the same session • Frenu WHAT? • Incident too

A Coders Role • Medical coders hold a key role in the success of many types of health care

companies.

• Physicians need to understand coding - to appreciate the details that must be documented in their dictation to support coding of the procedure performed

• We need to have the ability to discuss discrepancies.

• (“if it wasn’t documented, it wasn’t done”) – We can’t assume

• Example: If a provider submits for total ethmoidectomy (31255) The documentation must include details of surgery on the posterior ethmoid cells. Not just the anterior cells.

Surgical Guidelines • In defining the specific services "included" in a given CPT surgical code, the

following services related to the surgery when furnished by the physician or other qualified health care professional who performs the surgery are included.

• Evaluation and Management (E/M) service(s) subsequent to the decision for surgery on the day before and/or day of surgery (including history and physical)

• Local infiltration, metacarpal/metatarsal/digital block or topical anesthesia

• Immediate postoperative care, including dictating operative notes, talking with the family and other physicians or other qualified health care professionals

• Writing orders

• Evaluating the patient in the post anesthesia recovery area

• Typical postoperative follow-up care

Botox • BOTOX is used to treat a variety of problems with the voice box,

including spasmodic dysphonia, laryngospasm, and granulomas

• BOTOX is also used for some facial nerve disorders such as Melkersson's syndrome

• These are a just a couple reimbursable, medically necessary uses for Botox injections in the ENT setting.

• Appropriate documentation and coding for the administration of Botox is key

• Lets look at a couple of examples

Botox Examples • Dr. A preps the patient for Botox injection of vocal cords. After consent and prep. Patients

vocal cords are visualized. Using flexible laryngoscope 80 units of Botox are injected into both the right and left vocal cords. There were 20 units left in the vial.

• 31570

• J0585 Units 80

• J0585 JW Units 20

Botox Examples • Dr. B preps the patient for Botox injection into the facial nerve for Bells Palsy. After

consent and prep, The region above the overactive muscle is cleansed with alcohol and 155 units of Botox are injected.

• 64612

• J0585 155 Units

• J0585 JW 45 Units

Closed Treatment Nasal Fracture

21315 = Closed Treatment Nasal Fracture WITHOUT Stabilization

• The physician treats a displaced nasal fracture by manipulating the fractured bones. The physician places nasal elevators or forceps into the nose and realigns the nasal bones. After the bones are realigned, they are stable and require no additional stabilization with splints.

Closed Treatment Nasal Fracture

• 21320 = Closed Treatment Nasal Fracture WITH Stabilization

• The physician treats a displaced nasal fracture by manipulating the nasal bones. The physician places nasal elevators or forceps into the nose and realigns the nasal bones. After the bones are realigned, they remain slightly mobile and require additional stabilization with splints. External splinting may consist of a cast taped to the reduced nose. Internal splinting consists of supporting the nasal septum by splints or packing with gauze strips.

Open Treatment Nasal Fracture

21325 = Open Treatment Nasal Fracture ( uncomplicated)

• The physician treats a displaced nasal fracture. After unsatisfactory results with closed manipulation of the fractured bones, the physician performs open treatment. Incisions are made inside the nose to expose the nasal septum and portions of the nasal bones. The physician realigns the fractured bones using nasal elevators and forceps. Intranasal incisions are closed in a single layer. Any lacerated skin areas are closed in layers. After the bones are realigned, they remain slightly mobile and require additional stabilization with splints.

Open treatment of Nasal Septal Fracture• 21336 = Open Treatment of Nasal Septal Fracture

• The physician makes an incision to repair a nasal septal fracture. Open treatment is necessary after unsatisfactory results with closed manipulation of the fractured septum. Incisions are made inside the nose. The nasal septum is exposed and portions of the fractured cartilaginous and bony septum are removed. Trans septal sutures are placed to prevent formation of a septal hematoma. Intranasal incisions are closed in single layers. Stabilization such as internal splinting may be used to support the septum during healing. Internal splinting consists of supporting the nasal septum by splints or packing with gauze strips.

Nasal Fractures • Open vs. Closed ?

• Using a butter knife and manual manipulation, fractured bone of the nose was easily moved. The outer part of the nose appeared to be straight. At this point a left hemitransfixion incision was made along the right mucoperiosteal tunnel. His cartilage of the septum was fairly shattered in multiple pieces. Visibly, these were realigned and it was elected not to remove any of the tissue as they did realign quite well. These septal mucosal flaps are approximated using 4-0 suture in a running through and through mattress type fashion. Incision closed using interrupted chromic suture. Silastic sheeting placed on either side of septum to splint this in and hold in position and secured in the usual fashion. The right side nose which was concave was packed with Surgicel to help support nasal bone out into its anatomic position. External nose then taped.

Cerumen Removal • Cerumen impairs the exam of clinically significant portions of the external auditory

canal

• Extremely hard, dry, pain, itching, hearing loss

• Cerumen could be associated with foul odor, infection and/or dermatitis

• How to code for patients impacted every two months?

• 69209 code does not have physician work relative value units (RVUs)

• CPT code 69210 vs 69209

Cerumen Removal • Effective 4/1/2017

• CMS reduced the number of MUEs for cerumen removal code 69209 (Removal impacted cerumen using irrigation/lavage, unilateral) from two to one.

CerumenMo went to the physicians office with complaints of crickets in his ears. Dr. Happy inspected the patients ear with an otoscope and found that the patient had hard impacted cerumen bilaterally. Dr. Happy then uses alligator forceps and suction to remove the impacted cerumen. The patient immediately felt relief of his symptoms.

• Instrumentation + Provider Requirement + Impacted Cerumen = 69210

Sally went to the doctor due to itchy ears. Nurse Rose looked in the patients ear and determined that she was going to lavage the ears for relief

• No Instrumentation + Nurse Visit + Non Impacted Cerumen = 69209

Tube Insertion/ Removals • Appropriate CPT code for Ventilating Ear Tube Removals in the office

• 9920X – 9921X

• Appropriate CPT code for Ventilating Ear Tube Removal in the operating room

• 69424

• Appropriate CPT code for Ventilating Ear Tube Insertions in the office

• 69433 ( Don’t forget your modifier ) -50 Increased RVU for practice expense

Diagnostic Endoscopies

• 31231 nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure)

• 31575 laryngoscopy, flexible; diagnostic

• 92511 nasopharyngoscopy with endoscope (separate procedure).

• 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 cannul diagnostication of ostium

Epistaxis

• 30901: control nasal hemorrhage, anterior, simple(limited cautery &/or packing) any method

• 30903: control nasal hemorrhage, anterior, complex (extensive cautery &/or packing) any method

• 30905: control nasal hemorrhage, posterior, with packs &/or cauterization, any method; initial

• 30906: control nasal hemorrhage, posterior, with packs &/or cauterization, any method; subsequent

Documentation critical to distinguish correct service

• Where is the bleed?

• Was it controlled with endoscopic visualization?

• What sources were used for control?

• Electrocautery

• Silver Nitrate

Example• How do you code the services?

Initial visit for patient with 3 weeks of intermittent nasal bleeding, mild but occasionally moderate.

• Perform & document level 3 initial visit care

• Identify left anterior bleeding site and control with silver nitrate cautery and Surgicel topical pack

• Physician documents use of nasal endoscope during evaluation.

Answer

• 99203 -25

• 31238

Turbinates

• Common error is coding and billing for cautery of the turbinate's

Turbinates• AAO-HNS “Clinical Indicators” state that indications for inferior turbinate surgery must include:

• Chronic nasal obstruction due in part to inferior turbinate hypertrophy.

• Failure of directed medical management with continued nasal symptoms (medications, allergy treatment, and duration of therapy)

• Failure of medical treatment of rhinitis medicamentosa.

• Symptoms of obstructive sleep apnea

• The “failure of directed medical management” might be considered (particularly if YOU are the patient) to include:

• Continued obstruction following straightening nasal septum

• Continued obstruction following endoscopic sinus surgery

Turbinates• 30801: cautery and/or ablation, mucosa of inferior turbinates, unilat or bilat, any method;

superficial

• 30802: intramural (this includes radiofrequency procedures)

• 30930: fracture inferior turbinates, therapeutic

• 30130: excision inferior turbinate, partial or complete

• 30140: submucous resection of inferior turbinate, partial or complete, any method

• 30801, 30802, & 30930 are components of 30130 & 30140 Middle turbinate Rx (non-endoscopic), including concha bullosa, now coded as 30999 unlisted procedure

• 31240: endoscopic resection concha bullosa; NOT bundled into 31254 & 31255 per CCI

Turbinates – Example • Dr. Johns documented that he used a blade to submucosally excise tissue with

microdebrider and suction through a tube.

• Is CPT 30140 Correct ?

Turbinates – Answer• Code 30140 (Submucous resection inferior turbinate, partial or complete, any method)

specifies excision of bone. There must be documentation that your surgeon cut the mucosa to get to the bone and remove it, preserving the mucosa.

• If the surgeon removed the mucosa and bone together, the correct code would be 30130 (Excision inferior turbinate, partial or complete, any method).

Septal Cartilage Graft and Septoplasty• Physician performed a septoplasty, CPT 30520, removed

cartilage and fashioned it for a graft that he used in the surgical repair of vestibular stenosis, CPT 30465. Do you code 20912 for the fashioning of the graft or just 30520 and 30465?

• Only one code, 30520 or 20912, may be reported if the procedures were performed through the same incision. What was the reason for the incision – to straighten the septum (30520) or to obtain the graft (20912)? Use whichever code is supported by the documentation but do not use both codes. .

Nasal Valve Repair• Common mistakes

• 30465 and 30465 -50

• Use of -59 to correct denials

• CPT guidelines state to use modifier 52 (reduced services) on 30465 if only one side is corrected. Therefore, 30465 implies both sides were surgically corrected and it would be inappropriate to append modifier 50 (bilateral procedure)

Debridement

• An otolaryngologist may perform postoperative Debridements(31237, Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement (separate procedure) for sinusitis after Functional Endoscopic Sinus Surgery, which may also include Septopplasty and/or Turbinectomy, or Submucousresection inferior turbinate.

• The Medicare Physician Fee Schedule assigns different global periods to 30520, 30130-30140 and FESS codes. Codes 30520 and 30130-30140 have 90-day global periods. FESS codes contain zero global days.

Debridement

Example:

After a septoplasty for a deviated septum, a turbinectomy for hypertrophy, a total ethmoidectomy for ethmoidal sinusitis and a maxillectomy for maxillary sinusitis an otolaryngologist performs debridement. Documentation indicates the debridement was to remove the crusting that occurs following sinus surgery, to prevent infection and to keep the airway patent.

• Because the Otolatyngologist performed the debridement for a reason that is unrelated to the reason for the septoplasty and/or turbinectomy, you should report the debridement.

Debridement • Opinion: From an audit perspective, appropriateness of 31237 is not a coding issue; it typically is either:

• Documentation issue

• Documentation fails to meet AAO-HNS policy statement conditions to be considered a debridement (rather than just suctioning)

Drug Eluding Implant ( Propel)

• The Propel sinus implant is a steroid-releasing sinus implant that is inserted into the ethmoid sinus

• Indicated for patients 18 years or older

• Inserted under endoscopic visualization

• Once in place medication ( mometasome furoate) is released over a 30 day period.

• Documentation is key for proper reimbursement

Drug Eluding Implant ( Propel)Example

Code: 0406T

Procedure: Nasal endoscopy of ethmoid sinus with placement of drug-eluting implant

Procedure in detail:

The right nasal cavity was endoscopically examined with a rigid scope. The Propel implant inserter was placed into the nasal cavity and used to open and place the implant into the ethmoid cavity. Good placement was achieved within the cavity to provide maximal contact with the cavity surfaces and provide continuous medication to reduce inflammation and scarring and improve healing.

UPPP & Tonsillectomy Coding• 42145 - Palatopharyngoplasty (eg, uvulopalatopharyngoplasty,

uvulopharyngoplasty)

• 42825 - Tonsillectomy, primary or secondary; younger than age 12

• 42826- Tonsillectomy, primary or secondary; age 12 or over

• Code 42145(column 1) has a CCI conflict with code 42826(column 2). A modifier is not allowed to override this relationship.

• According to CCI data, there are not any CCI conflicts for 42826 and 42145

Vestibular Testing • An ENG is used to detect disorders of the peripheral vestibular system (the parts of the

inner ear that interpret balance and spatial orientation) or the nerves that connect the vestibular system to the brain and the muscles of the eye.

• Your provider might order an ENG if the patient is experiencing unexplained dizziness, vertigo, or hearing loss. Additional conditions that might warrant an ENG include acoustic neuroma, labyrinthitis, Usher syndrome, and Meniere’s disease.

• During the test, electrodes are placed at locations above and below the eye to record electrical activity. By measuring the changes in the electrical field within the eye, ENG can detect nystagmus (involuntary rapid eye movement) in response to various stimuli. If nystagmus does not occur on stimulation, a problem may exist within the ear, nerves that supply the ear, or certain parts of the brain. This test may also be used to distinguish between lesions in various parts of the brain and nervous system.

Vestibular Testing

• 92541, Spontaneous nystagmus test, including gaze and fixation nystagmus, with recording

• 92542, Positional nystagmus test, minimum of 4 positions, with recording

• 92544, Optokinetic nystagmus test, bidirectional, foveal or peripheral stimulation, with recording

• 92545, Oscillating tracking test, with recording.

• 92537, Caloric vestibular test with recording, bilateral; bithermal (i.e., one warm and once cool irrigation in each ear for a total of 4 irrigations.

• 92538, Monothermal (i.e., one irrigation in each ear for a total of two irrigations)

• 92540 – Basic vestibular evaluation, includes spontaneous nystagmus test with eccentric gaze fixation nystagmus, with recording, positional nystagmus test, minimum of 4 positions, with recording, optokinetic nystagmus test, bidirectional foveal and peripheral stimulation, with recording, and oscillating tracking test, with recording

Vestibular Testing

In 2016 CPT® introduced two new Caloric codes. 92537 (Caloric vestibular test withrecording, bilateral; bithermal [i.e., one warm and one cool irrigation in each ear for a totalof four irrigations]) and 92538 (… monothermal [i.e., one irrigation in each ear for a total oftwo irrigations]), are considered the Column 1 code when performed with several specificprocedures, a couple of them are 69209 and G0268

Frenulum Incision/ExcisionCPT code 40806

CPT code 41115

CPT code 41010

Global Period Modifiers• How Do They Impact Reimbursement?

• Modifier 58: Indicates that a subsequent procedure was performed as a (1) planned or anticipated (staged); (2) more extensive than the original procedure; or (3) for therapy following a surgical procedure. Reimbursement should be 100% of the allowable and the global period is extended to that of the subsequent procedure.

• Modifier 79: Is appended to CPT code to show that an unrelated procedure was performed during the global period of a prior procedure. Reimbursement should be at 100% of the allowable and you’re now in a separate global period that is related to the subsequent procedure.

• Modifiers 78: Indicates that an unplanned, related procedure was performed in the operating room, catheterization or endoscopy suite. Typically this is treatment of a complication such as wound dehiscence, infection, etc. Reimbursement is typically at 70-80% of the allowable.

• The reduction accounts for overlapping pre- and post-op care which was paid under the original procedure.

E/M with Procedure• Every procedure with a defined global period (including 90 day, 10 day, and 0

day) includes an E/M component

• This E/M component is described by CMS as “the usual pre- and post-operative work of a procedure with a global fee period”

• Each procedure code with a global period includes RVUs assigned for the usual E/M services associated with that code

• A physician should not submit codes for an E/M service that is within the description of “usual work” associated with a procedure

Exam Issues• Counting headers, not the content of the Exam.

• Counting Body Areas for a comprehensive Exam – 1995 Guidelines

• 1997 ENT Comprehensive Exam frequently missing bullets:

• Assessment of hearing with tuning forks and clinical speech reception thresholds (e.g., whispered voice, finger rub);

• Examination by mirror of larynx including the condition of the epiglottis, false vocal cords, true vocal cords and mobility of larynx (Use of mirror not required in children);

• Examination by mirror of nasopharynx including appearance of the mucosa, adenoids, posterior choanae and eustachian tubes (Use of mirror not required in children).

Diagnosis Coding • When a cancer has been removed and there is no evidence of recurrence,

and there is no active treatment, it would not be proper coding to continue to use the malignancy ICD-10 codes

• “personal history of…” section should be used

• In the absence of any signs or symptoms to suspect a recurrence, a surveillance scope is not covered by Medicare

• Provide an ABN (Advanced Beneficiary Notice)

Recent Release• For Medicare purposes, for an ABN to be considered valid, the provider

must use the most recent version of the CMS-R-131

• The Office of Management and Budget (OMB) periodically reviews the ABN (Form CMS-R-131) and in March of this year (2017) approved it for renewal

• Update all forms around office

Incident too "Incident to" services are defined as services or supplies furnished as an integral, although incidental, part of the physician's personal professional services in the course of diagnosis or treatment of an injury or illness. Reimbursement is based on 100% of the physician fee schedule amount.

Note: Services with their own benefit categories include: clinical lab services, flu shots, diagnostic services. These services do not fall under “incident to.”

Incident too •Applies to the following settings:

•Physician’s Office

•Patient’s home

•NOT inpatient services

OIG ReportOIG found that Medicare allowed physicians’ billings for more than 24 hours of services in a day:

•50% of the services were not performed by a physician. And of these, 21% of the services were performed by unqualified non-physicians

Incident-to services are a program vulnerability in that they do not appear in claims data and can be identified only by reviewing the medical record.

They may also be vulnerable to overutilization and expose beneficiaries to care that does not meet professional standards of quality.

What’s the issue?

• Depending on who actually performed the service, erroneous reporting could result in either a 15% or 100% overpayment.

• Auxiliary person is unlicensed – 100%

• Auxiliary person is licensed (NP/PA) but is not credentialed in the group – 100%

• Auxiliary person is licensed (NP/PA) and is credentialed in the group – 15%

The 5e Rule

What are the circumstances that must be met for the physician to be able to bill using his/her NPI for services provided by a member of his/her staff (PA/ARNP)?

•Employed NPP

•Enrolled NPP

•Established patient to physician

•Established problem to physician

•Established plan of care by physician

+ Physician’s direct supervision

NPPs and “Incident to”Never bill incident-to:

• New patients or consultations

• Established patient with a new problem

• In any inpatient setting

Can bill incident-to:

• Established patient, without a new problem, and with direct physician supervision

• Never assume a 3rd party payer recognizes NPP’s services as incident-to

• Verify whether the payer includes NPPs as covered providers.

• Two weeks ago, Dr. B diagnosed Mr. Smith with Dysphagia, and today Mr. Smith is in the office with Dr. B’s PA who’s determining whether the medication Dr. B prescribed is working, no changes were made in the course of treatment. Meanwhile, Dr. B is walking a golf course; however, his colleague Dr. Jones is in the office suite available if the PA needs him.

Can you bill Mr. Smith’s visit with the PA as incident-to?

Example 1

50

Yes.

This service can be billed “Incident to”.However, under Dr. Jones NPI as he is the one

who provided direct supervision.

Answer 1

51

Global Surgery Reporting • Effective for services 7/1/2017 and after

• Includes 10 and 90 day global services

• Report 99024 for each postoperative visit

• ENT has MANY codes to report within

What is a post op visit per CMS • Follow-up services performed during the post-operative period for reasons related to the original

procedure

• Visits that are covered by the global period are to be reported

• Visits can occur in all sites of care including, but not limited to, ICU, outpatient clinic, or skilled nursing facility . Relevant telehealth visits should also be reported if the patient is located at an eligible originating site

What Services to Report • Post-operative visits following selected procedures

• Procedures were selected based on 2014 data

o Furnished by more than 100 practitioners

o Performed 10,000 times or have allowed charges exceeding $10 million

• Changes in CPT coding have been accounted for

• Procedure codes subject to reporting will be updated yearly and published prior to beginning of reporting year

• NOTE: Reporting is not required for pre-operative visits within the global period or for services not related to a patient visit

Who Reports • Billing practitioners (physicians and non-physician practitioners) are required to report post-operative

visits if they:

o Practice in one of nine states randomly selected by CMS

• And

o Practice in a group of ten or more practitioners

• And

o Are part of a practice that provides global services under one of the required procedure codes

Practitioners who are not required to report are still encouraged to report post-operative visits. If you are voluntarily reporting, report all visits for all selected procedures

Selected States to ReportFlorida North Dakota

Ohio Kentucky

Oregon Louisiana

Rhode Island

Nevada

New Jersey

Mandatory reporting codes

Mandatory reporting codes

• 2017 AMA CPT Professional Addition

• Optum’s Encoder Pro

• Chapter 12 Section 40.2.8 of the Medicare Claims Processing Manual

• www.oig.gov

• www.cms.gov

References

Questions

CEU#