Otolaryngology Coding Alert

Labyrinthotomy code applies to perfusion of steroid, not just gentamicin

Using 90772 instead of 69801 for a steroid injection can cut more than $685 from a claim. So you-d better know when each code applies.

See if your otology coding is up-to-date with this scenario offered by Gloria Sikora with Trinity Ear Nose & Throat Clinic in Tyler, Texas. An otolaryngologist gave a transtympanic injection of a steroid for sudden hearing loss. -Due to health problems, the patient was unable to be treated by conventional methods,- Sikora says. The physician made no incision in the eardrum. -How would you code this?- she asks.

Extend 69801 to Steroid TM Injections

Our experts say you should code a transtympanic (TM) injection of drugs, such as steroids, with 69801 (Labyrinthotomy, with or without cryosurgery including other nonexcisional destructive procedures or perfusion of vestibuloactive drugs [single or multiple perfusions]; transcanal). -Code 69801 applies to perfusion treatment of the inner ear,- says Hayes H. Wanamaker, MD, chief of otolaryngology at Crouse Hospital in Syracuse, N.Y. 

Historically, 69801 has applied to gentamicin injections for Meniere's disease (386.00-386.04). But the code also applies to steroid injections for Meniere's disease, autoimmune inner ear disease, and sudden hearing loss. -The Association of Otolaryngology Administrators states that the drugs include anti-inflammatory steroids (such as depomedrol, solumedrol, Decadron) and aminoglycosides (such as gentamicin, streptomycin, etc.) based on the code description of vestibuloactive drugs,- says Lynda Wright, physician billing manager at the Vanderbilt Bill Wilkerson Center for Otolaryngology and Communication Sciences in Nashville, Tenn. -We mostly infuse dexamethasone, which falls into the category of anti-inflammatory steroids,- she adds.

Sidestep Myringotomy Pitfall

Be careful that you don't code steroid perfusion as a myringotomy (69421, Myringotomy including aspiration and/or Eustachian tube inflation), says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J. Otolaryngologists may administer steroids via a myringotomy with or without a tube, or via needle injection, but you should report these as TM perfusions using 69801.

Report Global Code Without 52

When reporting a TM injection of a steroid, do not attach modifier 52 (Reduced services) to 69801. The code does not require surgical labyrinthectomy. -Intratympanic administration (injection into the middle ear space) of aminoglycosides - is an alternative to surgical labyrinthectomy and vestibular nerve section for the treatment of refractory vertigo associated with Meniere's disease,- according to The Regence Group (Part B Medicare carrier for Idaho, Oregon, Utah and Washington) medical policy -Intratympanic Aminoglycoside and Corticosteroid Treatment for Meniere's Disease.- Chemical labyrinthectomy meets the criteria for using the full code without reduced services (modifier 52).

Key: To use 69801, the injection must be transtympanic. -The transtympanic perfusion of drugs procedure, which was added to code 69801 [in 1997], is a nonexcisional destructive procedure of the labyrinth in which vestibuloactive drugs are perfused transtympanically,- states CPT Assistant November 1996.

Switch to 90772 for IM Injections

If, however, a patient receives a steroid injection intramuscularly, you should instead code the administration with 90772 (Therapeutic, prophylactic or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular). For instance, you should code administration of a Decadron injection performed under direct physician supervision with 90772, not 69801. 

Payment: Because 69801 has a higher risk associated with the procedure than 90772 does, the 2007 National Physician Fee Schedule assigns significantly more work relative value units (RVU) to 69801 than to 90772--8.61 work RVUs for the TM injection code compared to 0.17 for the IM injection code. You can expect more than $685 in additional payment for 69801, which contains 18.61 transitional nonfacility (TRNF) total RVUs and pays $705.27 using the 2007 conversion factor of 37.8975. The fee schedule assigns 0.53 TRNF total RVUs to 90772, which equates to an unadjusted payment of $20.09.

Include Related Items With Initial Charge

Part of the disparity in payment stems from 69801's surgical package. You should report 69801 once, regardless of whether the patient returns for additional injections. Code -69801 includes all required infusions performed on initial and subsequent days of treatment,- according to the parenthetical instruction following the code in the CPT 2007 manual.

Otolaryngologists usually administer steroid perfusion -in a series of three injections spaced one to two weeks apart,- Wanamaker says. Because 69801 has 90 global days, the code includes all related office visits and injections during that time period, he says.

Don't Overlook Billing Meds, Tests

You can, however, report some related items in addition to 69801. Wanamaker says to bill:

- any balance or hearing testing as indicated
- J codes for the drugs such as:
- Decadron with J1100 (Injection, dexamethasone sodium phosphate, 1 mg)
- Depomedrol using J1020, J1030 or J1040 (various dosages of Injection, methylprednisolone acetate)
- gentamicin with J1580 (Injection, Garamycin, gentamicin, up to 80 mg).