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Wiki ENT 69440 with 69540 Coding ?

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RobynRas1

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HI,

Would welcome any input from ENT coders please. I have a provider asking to code 69440 for exploration but doing adhesion removal 69450 same ear same DOS. He feels that the 69440 exploration is the best CPT to use. The documentation clearly stating exploration and the finding and removal of adhesions. We are not finding edits to code both but feel it may be up coding to use both?

I sure would welcome anyone that might have had experience with this scenario in their experience.

Thank you
Robyn Rasmusson, RHIT
 
According to NCCI, you can bill both together.

Why did the patient come in to the office? Did they come in because they had some kind of symptom (pain, swelling,) and during the course of the exploration, the provider found and removed the adhesion? In that instance, I would code both.

If they came in specifically to have the adhesion removed, I would only code the adhesion removal, because while it might not technically be upcoding, it seems to me to meet the "spirit" of the definition: you have to look for the adhesion to remove it.
 
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