CPT® 2011 The Latest in ENT Procedures
From bronchoscopy to tongue excision and dizziness to drooling, here’s what’s new for ENT.
By Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CPC-I, CHCC, CENTC
CPT® 2011 brings more than a dozen code changes of particular relevance to ear, nose, and throat (ENT) practices. Among the most prominent is the addition of three codes to report endoscopic dilation of the sinus ostia:
31295 Nasal/sinus endoscopy, surgical; with dilation of maxillary sinus ostium
(eg, balloon dilation), transnasal or via canine fossa
31296 Nasal/sinus endoscopy, surgical; with dilation of frontal sinus ostium
(eg, balloon dilation)
Sinus ostia are narrow corridors connecting the sinuses to the nasal cavity. These pathways can become blocked, allowing sinus secretions to collect, which can lead to sinusitis and other problems. Codes 31295-31297 describe a relatively new technique, in which the surgeon inflates a balloon catheter in the affected ostium (maxillary, frontal, or sphenoid). The expanding balloon forcibly dilates the surrounding tissue. When the balloon is deflated and withdrawn, the ostium remains open. Fluoroscopy, when performed, is included in the dilation.
Like the sinuses, the ostia are paired structures (for instance, there is both a left and a right sphenoid sinus ostia); but per CPT® guidelines, 31295-31297 report unilateral procedures. If the surgeon dilates both the left and right sphenoid sinus ostia, for example, append modifier 50 Bilateral procedure to 31297. By contrast, if the surgeon dilates the left sphenoid sinus ostium and the right frontal sinus ostium, proper coding is 31296, 31297. Modifier 50 isn’t required because different (rather than paired) ostia were targeted.
When dilation occurs in the same sinus as another surgical, functional endoscopic service, the dilation in some cases may not be separately reportable. Per CPT® parenthetical instructions:
- Do not report 31295 in addition to 31233 Nasal/sinus endoscopy, diagnostic with maxillary sinusoscopy (via inferior meatus or canine fossa puncture), 31256 Nasal/sinus endoscopy, surgical, with maxillary antrostomy, or 31267 Nasal/sinus endoscopy, surgical, with removal of tissue from maxillary sinus when performed on the same sinus.
- Do not report 31296 in addition to 31276 Nasal/sinus endoscopy, surgical with frontal sinus exploration, with or without removal of tissue from frontal sinus when performed on the same sinus.
- Do not report 31297 in addition to 31235 Nasal/sinus endoscopy, diagnostic with sphenoid sinusoscopy (via puncture of sphenoidal face or cannulation of ostium, 31287 Nasal/sinus endoscopy, surgical, with sphenoidotomy, or 31288 Nasal/sinus endoscopy, surgical, with removal of tissue from the sphenoid sinus when performed on the same sinus.
As an example, if the surgeon dilates the left maxillary sinus and performs maxillary antrostomy with removal of tissue in the same sinus, claim 31267 only; the dilation (31295) should not be reported separately. If the dilation and antrostomy occurred at different locations, report each procedure separately, appending modifier 59 Distinct procedural service on the dilation code to represent a separate site.
Endoscopic Bronchopleural Fistula Occlusion Calls for 31634
Added code 31634 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with balloon occlusion, with assessment of air leak, with administration of occlusive substance (eg, fibrin glue), if performed also describes an endoscopic procedure using a balloon. In this case, the balloon is placed and inflated to occlude (block) a bronchopleural fistula (BPF)—an abnormal passageway between the lungs and pleura that allows inhaled air to escape the lungs into the pleural space. An occlusive substance, such as fibrin glue, may be administered to seal the fistula after the balloon has been removed. The procedure includes assessment of air leak, fluoroscopic guidance (to guide placement of the balloon), when performed, and moderate sedation.
BPFs occur most frequently due to infection or prior surgery. According to CPT® Changes 2011: An Insider’s Guide, endoscopic balloon occlusion “has been performed in the past as part of a last effort to resolve persistent bronchopleural fistulas. It is becoming more common as an earlier therapy for this disease.” Prior to 2011, the procedure was reported using an unlisted code.
Stereotactic Code Recognizes Extradural Procedures
Image-guided surgery allows for navigation and localization around high-risk anatomical structures. Code 61795, which previously described image-guided surgery, is deleted for 2011 and is replaced by three codes that describe the navigational procedure by location.
New code +61782 Stereotactic computer-assisted (navigational) procedure; cranial, extradural (List separately in addition to code for primary procedure) now describes image-guided surgery outside the cranium. In previous years, there was no way to differentiate extradural procedures from intradural procedures (now reported using +61781 Stereotactic computer-assisted (navigational) procedure; cranial, intradural (List separately in addition to code for primary procedure)) or spinal procedures (now reported using +61783 Stereotactic computer-assisted (navigational) procedure; spinal (list separately in addition to code for primary procedure)), which generally are limited to neurosurgical specialists.
Navigation is an add-on procedure reported in addition to a primary surgical procedure in the same area. For example, 61782 might accompany nasal surgical endoscopy with optic nerve decompression (31294).
Injection for Sialorrhea — 64611
Sialorrhea (drooling) may be a serious problem for some patients. Selective chemodenervation with botulinum toxin A may reduce saliva production. Code 64611 Chemodenervation of parotid and submandibular salivary glands, bilateral describes such an injection into the parotid and submandibular salivary glands. This is a bilateral code; if fewer than four salivary glands are injected, CPT® instructs you to append modifier 52 Reduced services to 64611.
Revised Labyrinthotomy No Longer Includes Subsequent Perfusions
Labryinthotomy may be performed to treat Ménière’s disease and/or vertigo. The descriptors for 69801 Labyrinthotomy, with perfusion of vestibuloactive drug(s); transcanal and 69802 Labyrinthotomy, with perfusion of vestibuloactive drug(s); with mastoidectomy have been revised to remove references to cryosurgery. According to CPT® Changes 2011: An Insider’s View, “Cryosurgery is no longer utilized, and the only type of nonexcisional destruction performed currently is the perfusion of vestibuloactive drugs.” For example, the physician makes an incision in the tympanic membrane (ear drum), inserts the needle, and perfuses gentimycin (among other vestibulactive drugs) into the middle ear. The perfused drug deadens the hair-like fibers that transmit balance information to the brain. Initially, the procedure may cause dizziness for several days or weeks. This eventually dissipates and the vertigo disappears.
Several treatments may be required. You may report 69801 only once per day; however, for 2011 the global period for 69801 has been changed from 90 days to zero days. As a result, you may report subsequent perfusions on different dates of service separately, along with the drug supply code.
CPT® additionally instructs that you may not report 69801 with 69420 Myringotomy including aspiration and/or eustachian tube inflation, 69421 Myringotomy including aspiration and/or eustachian tube inflation requiring general anesthesia, 69433 Tympanostomy (requiring insertion of ventilating tube), local or topical anesthesia, or 64636 Tympanostomy (requiring insertion of ventilating tube), general anesthesia when performed on the same ear.
Code 69802 describes labyrinthotomy, as above, along with mastoidectomy (excision to remove an infected portion of the mastoid bone). This procedure is reported rarely (13 cases in 2008, according to Charles Koopman, Jr., MD, who presented at the American Medical Association’s (AMA’s) CPT® and RBRVS 2011 Annual Symposium this past November).
Turn to Category III Codes for Automated Audiometry
CPT® 2011 adds five Category III codes to describe automated audiometry tests (e.g, Tympany Otogram™). Such automated exams diagnose hearing defects using various parameters as defined within the codes.
0208T Pure tone audiometry (threshold), automated; air only
0209T Pure tone audiometry (threshold), automated; air and bone
0210T Speech audiometry threshold, automated
0211T Speech audiometry threshold, automated; with speech recognition
0212T Comprehensive audiometry threshold evaluation and speech recognition (0209T, 0211T combined), automated
For audiometric testing using audiometers performed manually by a qualified health care professional, see 92551-92557.
CPT® 2011 Clarifies Vestibular Function Test Combo Confusion
Vestibular evaluations are used to diagnose the origin of symptoms such as dizziness and vertigo, and specifically to determine if something is wrong with the vestibular portion of the inner ear. If dizziness is not caused by the inner ear, it might be caused by brain disorders, another medical condition (e.g., low blood pressure), or even psychological issues (e.g., anxiety).
- A spontaneous nystagmus test
- A positional nystagmus test
- An optokinetic nystagmus test
- An oscillating tracking test
CPT® includes codes to report each of these component tests individually; however, if all components are performed together, you would report them using a single code, 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.
In past years, there was confusion about how to report the individual components of the vestibular evaluation if a complete evaluation was not performed. Parenthetic instructions within CPT® now clarify that if three or fewer of the above component tests are performed, in any combination, you may report each test separately, as follows:
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
For instance, for spontaneous nystagmus test and optokinetic nystagmus test, report 92541 and 92544. If these tests occurred along with positional nystagmus and oscillating tracking tests, report 92540 to describe all four components. Don’t report any single component (92541, 92542, 92544, or 92545) in addition to 92540.
Note, however, that codes describing caloric vestibular test (92543 Caloric vestibular test, each irrigation (binaural, bithermal stimulation constitutes 4 tests), with recording), vertical axis rotational testing (92546 Sinusoidal vertical axis rotational testing), and use of vertical electrodes (+92547 Use of vertical electrodes (List separately in addition to code for primary procedure) may be separately reported with 92540 or any legitimate combination (three or fewer) of 92541, 92542, 92544, and 92545.
Watch out for Tongue Excision/Flap Bundle
A revised parenthetical note in CPT® 2011 now disallows separate reporting of 41114 Excision of lesion of tongue with closure; anterior with local tongue flap with 41112 Excision of lesion of tongue with closure; anterior two-thirds or 41113 Excision of lesion of tongue with closure; posterior one-third. This is in direct opposition to earlier editions of CPT®, which instructed “List 41114 in addition to code 41112 or 41113.”
Be sure to update your coding. If flap repair (41114) occurs with excision (41112 or 41113), report only the excision.
Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, is president CRN Healthcare Solutions and senior coder and auditor for The Coding Network. She is consulting editor for Otolaryngology Coding Alert and has spoken, taught, and consulted widely on coding, reimbursement, compliance, and health care related topics nationally.