Otolaryngology Coding Alert

Tune in to these guidelines to ensure reimbursement and streamline billing.

While ENTs far less frequently perform biopsies of the upper respiratory tract than other surgical specialties, you should know exactly what to do when your operative report includes a biopsy in addition to the primary procedure.

While you may feel inclined to submit both services, you should be familiar with the guidelines in place that often restrict coders from doing so.

Take a look at these Correct Coding Initiative (NCCI) Policy Manual guidelines and a follow-up example for a clearer picture on when and when not to submit otolaryngologic surgical services with a separate biopsy code.

Conveniently Break Down NCCI Policies

Chapter V of the NCCI Policy Manual states specific instructions on how coders should address situations involving surgical procedures of the nose and sinus that also include biopsies:

“A biopsy performed in conjunction with a more extensive nasal/sinus procedure is not separately reportable unless the biopsy is examined pathologically prior to the more extensive procedure, and the decision to proceed with the more extensive procedure is based on the result of the pathologic examination.”

Based on these guidelines, NCCI lays out a very specific scenario in which it would be appropriate to bill for both services. However, in any scenario in which the provider opts to biopsy the specimen immediately before or following the underlying nasal or sinus procedure, the biopsy should not be billed separately. NCCI provides the following example:

“If a patient presents with nasal obstruction, sinus obstruction and multiple nasal polyps, it may be reasonable to perform a biopsy prior to, or in conjunction with, polypectomy and ethmoidectomy. A separate biopsy code (e.g., CPT^® code 31237 (Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement (separate procedure)) for nasal/sinus endoscopy shall not be reported with the removal nasal/sinus endoscopy code (e.g., CPT^® code 31255 (Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior)) because the biopsy tissue is procured as part of the surgery, not to establish the need for surgery.”

Incorporate NCCI Policy Into This Clinical Example

Consider a scenario, unrelated to the sinuses, in which a biopsy is performed in the days leading up to the removal of a confirmed malignancy. In this case, you may bill out the biopsy in addition to the surgical removal procedure. However, you will want to take the global period of the biopsy procedure into account first.

Example: The provider performs a percutaneous core needle biopsy on a patient with a thyroid mass. The results come back positive for malignancy, and the provider performs a partial right thyroid lobectomy three days later.

Based on the guidelines, this situation clearly allows for both services to be billed. However, the coding of the thyroid lobectomy depends on the global period of code 60100 (Biopsy thyroid, percutaneous core needle). Since the global period is 0 days, you do not have to worry about reporting a modifier alongside code 60210 (Partial thyroid lobectomy, unilateral; with or without isthmusectomy). However, if the global period happened to be 10 days, for instance, you would report modifier 58 (Staged or Related Procedure or Service by the same physician or other qualified health care professional During the Postoperative Period ) with code 60210.

Keep in mind that if the provider performed these two services during the same surgical encounter, you should not code for the biopsy. The NCCI edit between 60200 and 60210 has a modifier status indicator of “1,” which means an overriding modifier may be placed on 60200 (column 2 code) under certain circumstances. However, the circumstances of this clinical scenario do not warrant the use of modifier 59 (Distinct Procedural Service) or modifier 58.

“This falls under the general premise that anything removed from the body is sent to pathology for biopsy,” explains Leslie Johnson, CPC, coding and auditing consultant at Oasis Medical and Surgical Wellness Group, LLC, in Glen Rock, New Jersey. “The edit exists because there may be times when a biopsy is done ‘first,’ and the results lead to the decision for the removal of an organ or excision of the tumor. In that instance, you can code the biopsy and also code the removal of the organ using modifier 58, when applicable,” Johnson details.

Johnson further explains that, despite the fact that 60200 has a global period of 0 days, you should still consider modifier 58 when the results of a biopsy call for a same-day removal of an organ. “The reason for this,” as Johnson explains, “is because of various risk factors and best possible outcomes that are determined by the results of the biopsy, which may call for the provider to do a more extensive or invasive procedure on the same day. The surgeon’s decision depends on the pathology results, which is why the term ‘staged’ applies.”

Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, AAPC Fellow, of CRN Healthcare in Tinton Falls, New Jersey, reiterates these sentiments, stating that, “if the documentation indicates that the decision to proceed with the partial thyroid lobectomy was made based on the pathology result of the needle core biopsy, the 58 modifier may be used and both the needle core biopsy and the partial thyroid lobectomy may be coded and billed on the same day.”