Otolaryngology Coding Alert

These two modifiers are must-haves when your physician performs custom tracheal resections.

Otolaryngology coding can hold surprises. For example, suppose your surgeon plans to perform a bilateral neck dissection with thyroidectomy and trachea resection but ends up having to also perform plate stabilization for access to the lymph nodes in the superior mediastinum. You can overcome this challenge with a thorough review of the documentation and careful use of modifiers. Still need convincing?

Consider the following op report, submitted to Otolaryngology Coding Alert by Julie Keene, CPC, CENTC, otolaryngology coding and reimbursement specialist with UC Health in Cincinnati, Ohio. After you review the op note, code the procedures before you check out our expert advice below.

Preoperative diagnosis: Medullary carcinoma of the right lobe of the thyroid, stage T4-A, N1-B, M0.

Procedure overview: Another ENT previously started a total thyroidectomy on this patient but found that the cancer was eroding into the trachea, so he referred the patient to this surgeon. The new surgeon performed a right modified radical neck dissection with preservation of the spinal accessory nerve and sternocleidomastoid muscle, as well as a left selective neck dissection, removing the lymph node levels II through IV.

He also performed a right thyroidectomy, a resection of the right lateral trachea, and osteotomy of the right clavicle with plate stabilization for access to lymph nodes in the superior mediastinum.

Op Note: Trace the Surgeon's Work

The pertinent details of the op report: We performed a modified radical neck dissection on the right neck, with preservation of the spinal accessory nerve and sternocleidomastoid muscle. We found that the internal jugular vein was involved by disease at level IV, and therefore sacrificed the internal jugular vein along with the rest of the neck contents. As we tracked the disease near the phrenic nerve, we saw that the disease was tracking down into the superior mediastinum and possibly involved the right subclavian vein.

We fractured the clavicle using a Gigli saw to offer better exposure to the vasculature in the superior mediastinum. We removed the lymph nodes that were tracking down along the carotid artery and jugular vein. We then performed a left neck dissection, removing lymph node levels II, III and IV.

We separated the fascia from the deep surfaces of the sternocleidomastoid muscle, which allowed us to remove the lymph node tissue from levels II, III and IV, bringing it anteriorly across the great vessels. Once we had it into the anterior aspect of temperature neck, we terminated the specimen and sent it to pathology.

We then started to remove the right lobe of the thyroid, which was easy to mobilize inferiorly. However, in the superior pole, there was obvious disease invading the trachea, so we had to cut into the trachea to remove the tissue. Once we were into the trachea, we realized that the esophagus could be involved. We carefully dissected along the level of the esophageal musculature to remove the tumor while leaving the esophagus intact.

We had to sacrifice the spinal accessory nerve because it was grossly invaded by the tumor. After removing the tissue, we had a moderate-size hole in the trachea. We mobilized the posterior wall of the trachea off of the esophagus, which allowed for a mucosal closure right to the tracheal cartilage. We sutured the tracheal hole closed, then used some of the esophageal musculature as a second layer of closure. We brought some of the remaining sternocleidomastoid muscle over to provide a third layer of closure. We decided not to do a tracheotomy on this patient.

We then got the mandibular reconstruction plating system out so we could put a plate on the clavicle. We were able to put three holes on each side of the osteotomy and screwed the plate into position. The clavicle appeared to be rigidly fixated. We then closed the wound over the two large Hemovac drains that we had placed.

Coding recommendations: Can you figure out the best way to code this complex op note? Determine how you would code the procedures, and then read on to see how our expert coded it.

Step 1: Report the Thyroidectomy.

The surgeon references "tracheal resection" in his documentation, but what he actually did was address the right lobe tumor invading across into the nearby tracheal structure, says Andrew Borden CCS-P, CPC, reimbursement manager for the otolaryngology department at Medical College of Wisconsin in Milwaukee.

The thyroidectomy in this note is really a completion thyroidectomy because the previous ENT, who was unable to perform the entire surgery, took the left thyroid already before he closed the patient," Borden says.

Find the clues: If you don't see the reference to this in the op report, remember that the op report shows a cancer diagnosis that should indicate a bilateral resection; however, the surgeon only documents removal of the right thyroid. The surgeon who "started a total thyroidectomy" must have already removed the left thyroid.

Therefore, you should report 60260-22 (Thyroidectomy, removal of all remaining thyroid tissue following previous removal of a portion of thyroid; Increased procedural services) for this service. Add the 22 modifier to indicate the extra extension of the thyroid resection, which precluded taking a piece of trachea, Borden recommends.

Step 2: Report the Wound Closure

The surgeon performed the multi-layered tracheal wound closure by using esophageal and sternocleidomastoid (SCM) muscles. Because this makes up a rotated muscle flap, you can report 15732 (Muscle, myocutaneous, or fasciocutaneous flap; head and neck [e.g., temporalis, masseter muscle, sternocleidomastoid, levator scapulae]).

Reminder: Only report 15732 if your documentation very clearly describes a rotated muscle flap in meticulous detail. Our operative report summary above does not sufficiently describe the procedure, Borden says, but an unedited operative report should go into detail about how the surgeon created the muscle flap and performed the closure.

Tip: Unlike free grafts or adjacent tissue transfers, muscle, you should code myocutaneous or fasciocutaneous flaps based on the donor site of the flap, not the defect site. Also, although the physician performs multiple flaps, you should only report one flap per defect. In other words, you should report 15732 only once.

Step 3: Report the Osteotomy

The surgeon describes an osteotomy of the clavicle to gain access to the lymph nodes in the superior mediastinum, but the documentation details reveal that the surgeon actually performed a mediastinal/tracheal lymphadenectomy via neck approach.

You might consider reporting +38746 (Thoracic lymphadenectomy, regional, including mediastinal and peritracheal nodes [list separately in addition to code for primary procedure]) for this procedure.

The challenge: "Code 38746 does describe much of the work associated with the procedure," Borden says, "however, it assumes a thoracic approach."

You should report 38999 (Unlisted procedure, hemic or lymphatic system) and use 38746 as the comparative code for pricing. "The extra work represented by the thoracic incision and approach would be comparable to the difficulty that the surgeon in this operative report had in utilizing an extensive neck dissection or the clavicle osteotomy approach," Borden says.

Step 4: Bill the Clavicle Procedure

"I would separately bill for the closure of the bony defect, which required reconstructive plating," Borden says. Therefore, you should report 23929 (Unlisted procedure, shoulder) for the plate reconstruction.

Twist: If the surgeon had performed non-fracture type plating, you would instead report 21299 (Unlisted craniofacial and maxillofacial procedure) for the mandibular reconstruction with plating.

Step 5: Code the Bilateral Lymphadenectomies

You should use your left- and right-side modifiers for the neck lymphadenectomies, Borden says. Report 38724-50 (Cervical lymphadenectomy [modified radical neck dissection]; Bilateral procedure) for this service. And some payers may require you to add modifier 51 (Multiple procedures) to the second and subsequent line items.

Therefore, your claim should appear as:

• 60260-22
• 38724-50-51
• 38999-51
• 23929-51
• 15732-51.

Remember: You will have to send in the documentation and give existing procedures to compare the unlisted procedures to assist the payer in pricing the unlisted procedures.