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Documentation & Coding Compliance forOtolaryngology – Head & Neck SurgeryStephen R. Levinson, claimer This presentation is designed to provideaccurate and authoritative information inregard to the subject matter covered. Theinformation includes both reporting andinterpretation of materials in variouspublications, as well as interpretation ofpolicies of various organizations. Thisinformation is subject to individualinterpretation and to changes over time Presenter has personal interests in consulting,presenting, writing about, and developingsoftware in order to help physicians achievecompliant medical records and to help themfacilitate quality patient careASA,LLCAttendee Demographics Physician offices Hospital / Academic MedicalCenter Medicare / Insurers Consultant HIT Other1

Today’s Agenda: Otolaryngology - HNSPrinciples of procedure coding– Selecting appropriate codes– When and how to use procedure modifiers Ear and Balance ProceduresNose & Sinus ProceduresOropharynx & Head & Neck ProceduresPlastic & Reconstructive ProceduresCoding E/M & procedures on same DOS ?– Codes with XXX global designation– E/M modifiers and how to use them compliantly– Office diagnostic procedures (0 & 10 day global)Compliance Tools CPT (AMA) ICD-9 (AMA) RBRVS for Physicians– RVUs– Global periods CCI www. ENTcodingtoday.com,Encoder Pro, or other webbased toolsSetting the Table Discussion is NOT about black &white rules, but about principles& tools and working in the grayzone Format – open dialogue withquestions and critiques– Umpty-three thousand ENT codes;please ask about those of interest– NOT the med school definition of a“lecture”2

Medical Record Formats? – MDs/staff Data Storage– Paper– Electronic EHR Scanning system Data entry– Writing on paper– Dictation Transcription Voice recognition software Using some form of template foroperative reports?– In O.R.– In officeCoding Practices Who does coding for Procedures– Physician primary– Coder primary– Is there review when questions? Who does coding for E/M services– Physician primary– Coder primary– Is there review when questions? Are there educational conferencesscheduled with coders & MDs– Regularly scheduled group sessions– As needed group sessionsCoding Procedure Services3

Coders’ Role in Procedure Coding When coder does primarycoding: Review operative report– Operation performed sectionis only the starting point– Must review details of opreport to confirm accuracy ofoperative designation– Then select appropriatecode(s) If any question ofdocumentation or coding,must review with physician When the physician doesthe primary coding: Coder reviews the report toconfirm that documentationsupports the submittedcodes– And to assess if additionalprocedures were alsoperformed that should becoded If any question ofdocumentation or coding,must review with physicianCoders’ Role as Educator Physicians need understand coding - to appreciate thedetails that must be documented in their dictation tosupport coding of the procedure performed– For example, if physician submits code for totalethmoidectomy (31255) must document performance ofsurgery on the posterior ethmoid cells– (“if it wasn’t documented, it wasn’t done”) Should discuss any discrepancies, add a dated correctionnote if necessary (and if appropriate) Should lead to prevention of discrepancies in futurecasesCoders’ Tools for Auditing Procedures CPT (AMA)ICD-9 (AMA)HCPCS Level IIMedical Dictionary?Anatomy book (e.g., Netter)Photocopy of operative noteHighlighter4

Suggested Architecture (Template)for an Op Note Patient informationSurgeonDate of OperationOperation PerformedPre-op diagnosisPost-op diagnosis Indications for surgery Operative findings Procedure - detailed andprocedure specificdescription of operationUse of Macros ? Which components ofprocedure description areacceptable for macro?The Rubber Stamp– Even for this, need protectionby separate sections forindications and operativefindings Which are not?EHRs, Cloned Documents, & Medical Necessity “Cloned documentation does not meet medicalnecessity requirements for coverage of servicesrendered due to the lack of specific, individualinformation.All documentation in the medical record mustbe specific to the patient and her/his situationat the time of the encounterCloning of documentation is considered amisrepresentation of the medical necessityrequirement for coverage of services.Identification of this type of documentation willlead to denial of services for lack of medicalnecessity and recoupment of all overpaymentsmade.”No Rubber Stamp– Eugene J. Winter, M.D., Medical Director for FirstCoast Service Options, Inc.– materials/medicaid/Medicare Document.pdf5

The Foundation Guidelines for Coding AnyProcedure (CPT Introduction) “Select the name of the procedure orservice that accurately identifies theservice performed. Do not select a CPTcode that merely approximates theservice provided. If no such procedureor service exists, then report the serviceusing the appropriate unlisted procedureor service code” “When necessary, modifying orextenuating circumstances are added” “Any service or procedure should beadequately documented in the medrecord”Guidelines for Coding Multiple Procedures All procedure codes (except thosedesignated XXX) include a CPTdefined surgical package:– Local or topical anesthesia– One related E/M encounter on day of (orone day before) the procedure,subsequent to the decision for surgery– Immediate post-op care, includingdictation and communication withfamily and/or other physicians– Evaluation in recovery area– “Typical postoperative follow-up care”What is Included in “ Typical” Follow-Up? “Follow-up care for therapeuticsurgical procedures includes only thatcare which is usually a part of thesurgical service. Complications,exacerbations, recurrence, or thepresence of other diseases of otherdiseases or injuries requiringadditional services should beseparately reported” Be aware (& wary) of the CMS noncompliant variation on this package– Complications ARE included in theirglobal package6

Modifiers When 1 procedure performed on same date,several modifiers may apply (as defined inAppendix A of CPT) Without the appropriate use of modifiers, insurersoftware will bundle all services into a primary code Do not submit codes for two procedures when one isa component of the other Modifiers: -51, -59Commonly Used Procedure Modifiers -22 unusual services: greater than usually required -50 bilateral procedure: Used to identify performingidentical operations on both sides for services thatare not already identified as bilateral in CPT– E.g., 31254.50– 42826 does not need a modifier since the RVU vignettedescribes this as a unilateral procedure -51 multiple procedures: used only when proceduresare not components– Advises insurer software to pay both services– Also triggers (by convention) a 50% reduction on allsecondary procedures (except add-on & -51 mod exempt)Commonly Used Procedure Modifiers -58 performance of a planned or staged procedureduring the post-operative period -59 distinct procedure service: one procedure thatwould normally be a component of another (&therefore not submitted) is being submitted becauseit was appropriate due to different site, differentencounter, separate lesion, etc– Used only when a different modifier not appropriate -62 two co-surgeons performing distinct parts of aprocedure– What is payment policy of Medicare & insurers on thismodifier?– What are the consequences?7

Commonly Used Procedure Modifiers -76 repeat procedure by same physician -77 repeat procedure by another physician -78 return to O.R. for a related procedure duringpost-op period (usually due to unexpected complics) -79 return to O.R. for unrelated procedure duringpost-op pd -80 assistant surgeon– What is payment policy of Medicare & insurers on thiscode?– What are the consequences?Managed Care Non-Compliant Policies forE/M Codes with Procedure Modifiers Some turn off modifier functionality(i.e., pay only one code regardless ofmodifier) Non-compliant bundling edits thatoverride the correctly used modifier– How many CCI edits?– How many Claim Check edits?– Suggest visiting www.CignaForHCP.comQuestions on Principles for Procedures?8

Ear ProceduresEar Wax 101 CPT code 69210– “Removal impacted cerumen” – define?– (separate procedure), one or both ears”– What is the global period designation for this procedure? How should this be coded when performed with another earprocedure (e.g., 69436 – tube placement)? How should this be coded with E/M service– When cerumen is the only reason for the visit?– When there is another problem addressed as well?– What must be documented in the chart for necessity? Compliance problem when every occurrence of wax is “impacted” (this failsto pass the smell test) How to code for patients impacted every two months?Using the Operating Microscope CPT code 92504This is a separate procedureThis has an XXX global designation0.69 RVUsCan 92504 be billed with cerumen removal code?– CPT Asst 7/2005: permissible if required (document medicalnecessity!); not if used routinely Should 92504 be billed for routine ear examination? Under what circumstances is this service billable? What isthe documentation required? CPT Asst (1/2005) advises use .52 modifier if unilateral9

What About the Add-On Code for Usingthe Operating Microscope? “Surgical microscope is employedwhen using the techniques ofmicrosurgery” Code 69990 should be reported (withoutmodifier –51) in addition to the code forthe primary procedure “Do not report code 69990 where use ofthe operating microscope is an inclusivecomponent” Although CPT’s example list of codes notto add 69990 does not include any earoperations, it is not a comprehensive list The RVU vignettes for ear surgery codesinclude use of the operating microscope!69990Tube Insertion Local anesthesia (office): 69433 / .50 bilat General anesthesia (office): 69436 / .50 bilatTube Removal (the 750tube removals) Tube removal in office: E/M Tube removal general anesthesia (unilat): 69424 (1.6RVU) ? Repair, with or without preparation of perf, with orwithout patch: 69610 (7.73 RVUs) ? Myringoplasty: 69620 (12.49 RVU)10

Coding for Acoustic Neuroma This is NOT a “skull basesurgery” The 2 codes that “accuratelyidentify the procedureperformed are– 61526: craniectomy, bone flapcraniotomy, transtemporal(mastoid) for excision ofcerebellopontine angle tumor;”– 61530: “combined withmiddle/posterior fossacraniotomy/craniectomy”Other Ear Questions? Mastoid? Stapes?Nose & Sinus Procedures11