Zoom in on the Rules for Reporting +69990 with Ear Procedures

CPT® tells us when not to separately report the use of an operating microscope. We’ll tell you when you should.

By Kim Pollock, RN, MBA, CPC, CMDP
Many otolaryngologists use an operating microscope when performing ear procedures in the operating room. Coders often wonder if it is acceptable to report CPT® +69990 Microsurgical techniques, requiring use of operating microscope (List separately in addition to code for primary procedure) in addition to the primary ear procedure code.
The first thing to note is that +69990 is an add-on code. The (+) symbol that appears to the left of the code in CPT® means the code may be reported only with an appropriate standalone, or primary, procedure code. CPT® says this code is for the technique of microsurgery via an operating microscope, and not for visualization with loupes or to correct vision.
CPT® also says not to use +69990 when it is considered an inclusive part of the primary procedure or another standalone code performed at the same operative session. CPT® lists the following codes where +69990 is considered inclusive: 15756-15758, 15842, 19364, 19368, 20955-20962, 20969-20973, 22551, 22552, 22856-22861, 26551-26554, 26556, 31526, 31531, 31536, 31541, 31545, 31546, 31561, 31571, 43116, 43180, 43496, 46601, 46607, 49906, 61548, 63075-63078, 64727, 64820-64823, 65091-68850, 0184T, 0308T, 0402T.
Some of the “inclusive” codes make sense, such as the microvascular free flap codes 15756-15758. The operating microscope is inherent in microvascular procedures. Another common standalone code where the microscope is considered inclusive and not separately reported is endoscopy code 31541 Laryngoscopy, direct, operative, with excision of tumor and/or stripping of vocal cords or epiglottis; with operating microscope or telescope [emphasis added]. 
CPT® does not list any of the auditory system/otology CPT® codes (69000-69979) as inclusive of the operating microscope. Should +69990 always be billed with an auditory system code when the operating microscope is used to perform the procedure? Absolutely not.

+69990 History 

Knowing the history of +69990 can help you determine when to use it. This code was introduced in 1999 to replace multiple ways to report microdissection by way of an operating microscope. At the time, there were a minimum of three ways to report this service:

1. 61712 Microdissection, intracranial or spinal procedure (list separately in addition to code for primary procedure)
2. 64830 Microdissection and/or microrepair of nerve (list separately in addition to code for nerve repair)
3. Modifier 20 (microsurgery)

CPT® +61712 was an add-on code to an intracranial or spinal primary procedure code, and not appropriate for use with an auditory system (otology) code. CPT® +64830 was an add-on code to a nerve repair primary procedure code and also not appropriate for use with most of auditory system codes (e.g., tympanostomy tubes, removal of foreign body, cerumen removal).
To reduce coding redundancies in the system, CPT® deleted these and other codes and instituted one code: +69990. CPT® +69990 was added to the Surgery section under a new section, called “Operating Microscope.” It is not considered an auditory system code (69000-69979).

When Should Otolaryngologists Report +69990?

Report +69990 when the operating microscope is used for necessary dissection of fine structures (e.g., blood vessels, nerves) to perform the procedure, and this is clearly documented in the operative report. It is not appropriate to report +69990 with auditory procedures
such as:

• Placement of tympanostomy tubes (69433 Tympanostomy (requiring insertion of ventilating tube), local or topical anesthesia and 69436 Tympanostomy (requiring insertion of ventilating tube), general anesthesia)
• Cerumen removal (69210 Removal impacted cerumen instrumentation, unilateral)
• Foreign body removal (69200 Removal foreign body from external auditory canal; without general anesthesia and 69205 Removal foreign body from external auditory canal; with general anesthesia)

The microscope is not being used for microsurgery in these instances.
Although CPT® allows reporting +69990 with, for example, 69950 Vestibular nerve section, transcranial approach, many payers, including Medicare, do not allow payment because they consider the use of the operating microscope inclusive to all auditory system CPT® codes.

Kim Pollock, RN, MBA, CPC, CMDP, is a senior consultant and speaker with KarenZupko & Associates, Inc., a physician practice management consulting and training firm based in Chicago, Ill. She is on the faculty for the American Association of Neurological Surgeons coding and reimbursement courses. Pollock has recently co-authored the book The Essential Guide to Coding in Otolaryngology.

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Kim Pollock

Senior Consultant at Karen Zupko & Associates

Kim Pollock, RN, MBA, CPC, CMDP, is a senior consultant and speaker with Karen Zupko & Associates, Inc., a physician practice management consulting and training firm based in Chicago, Ill. She is on the faculty for the American Association of Neurological Surgeons coding and reimbursement courses. Pollock has recently co-authored the book The Essential Guide to Coding in Otolaryngology.

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