Grab Extra $368 in Ethical Reimbursement to Your Cyst Excision Claims

Mixing up branchial and preauricular cysts can put you in the wrong CPT section.

Unless you comprehend neck and ear anatomy, you could lose precious dollars for your otolaryngology practice. In case your ENT carries out a facial tissue transfer (14040) and you report branchial cleft cyst excision (42810) as an alternative, you’ll lose 10.82 relative value units -- which is $368 of lost revenue. Know if your vocab is up to par by examining the following operative report and also know what CPT codes apply.

Code This Excision

Procedure: Excision of left preauricular first branchial cleft sinus tract in a earlier operated field.

Pre-/postoperative diagnosis(es): Intermittent left preauricular first branchial cleft sinus tract.

Note: This procedure qualifies for modifier 22 as it is a revision surgery in a previously operated field.

Specimens sent to lab: Overlying skin as well as the deep sinus tract.

Indications for surgery: Intermittent left preauricular sinus tract.

Findings in surgery: Scarred preauricular areas from previous excision with no cutaneous fistula and no distinct sinus tract.

Procedure: … An incision was made with the #11 scalpel blade everywhere in the area that the parents had specified most recently drained. This area was above the tragal cartilage region. A portion of the tragal cartilage was transected as the deep plane of the excision. Then, dissection was performed inferiorly and superiorly besides anteriorly to eliminate this portion of the pretragal scar and deep tissue. The depth of the dissection was the parotid gland. It was obvious that there was a huge amount of scar tissue at the anterior excision site, and this was felt to also comprise branchial cleft sinus tissue. Consequently, additional excision of the scar was carried out with the #11 and #15 scalpels, and a huge portion of tissue removed down to and comprising a portion of the superficial aspect of the parotid gland....

Next to the removal of the specimen, a noteworthy defect was present in the preauricular region. The closure of this area needed undermining the facial skin inferior to the oracle and after that anteriorly about one-third to 40 percent of the way to the corner of the mouth and lateral canthus of the eye. After that the tissue advanced and portion of the tissue rotated to allow a closure in a parotidectomy or fascial fashion in the preauricular area with a T-segment going anteriorly at the level of the tragus. Plicating 3-0 chromic sutures were used to reduce the space made vacant by excision of the deep tissue. This closure of the deep space was made potential by advancing the adipose tissue posteriorly and superiorly. Yet again, this tissue was held in place with 3-0 chromic suture.

Check Cleft Type

Recognizing whether the cyst excision was in the neck or ear region evades using a CPT code from an incorrect CPT anatomy section.

Make ceratin that you don’t lump branchial and preauricular cysts. Each is from a different embryological source.

Link Branchial to Neck’s 42810-42815

For branchial cysts, you’ll be in the neck section. Brachial cleft cysts are congenital cysts that arise in the lateral aspect of the neck when the second branchial cleft fails to close during embryonic development. At about the fourth week of embryonic life, four branchial (or pharyngeal) clefts develop between five ridges termed as the branchial (or pharyngeal) arches. These arches and clefts contribute to the development of various structures of the head and neck.

You must use CPT code 42810 (Excision branchial cleft cyst or vestige, confined to skin and subcutaneous tissues) once the branchial cyst is superficial. In case the provider dissects all the way to the tongue base or tonsillar pillars, you must report CPT code 42815 (Excision branchial cleft cyst, vestige, or fistula, extending beneath subcutaneous tissues and/or into pharynx).

Think Ear for Preauricular Cyst

Preauricular cysts come from the six hillocks that form the external ear.

Result: You can’t use CPT code 42810 or 42815 for the above operative report. This is a preauricular sinus track, and you should use 42815 when the cyst is in the neck around the tonsil area.

CPT 2012 Update: Revisions Expand Your Prolonged Services Reporting Scope

2012 CPT® revision opens opportunity of using code by every specialty.

When your gastroenterologist examines a patient for a condition for instance protracted vomiting, ICD-9 code 787.03, necessitating in-office medication and observation or obstipation/ impaction (564.09, 560.3) needing in-office enema or disimpaction, you might be able reporting prolonged services codes +99354 and +99355 in order to capture the time and work. The good news is that a CPT® 2012 revision permits you even more bandwidth in using these codes. Read on for advice on correct reporting with this change.

Broaden Office or Outpatient Prolonged Services

In 2012, you’ll have more tractability as far as applying office or outpatient prolonged services code +99354 is concerned, credit goes to this provider-related CPT® 2012 revision:

Old way: +99354 – (Prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual service; first hour [List separately besides code for office or further outpatient Evaluation and Management service].

New way: +99354 (Prolonged service in the office or other outpatient setting requiring direct patient contact further than the usual service; first hour [List separately besides code for office or further outpatient Evaluation and Management service]).

Big change in 2012: As per CPT® 2012 revision, the latest descriptor removes the words "physician" and "face-to-face", which extends the scope for reporting prolonged services. The descriptor is now apt for use by a wider range of providers and is not restrained for face-to-face physician services offered in an outpatient or office setting.

Likewise, the additional 30-minute CPT codes follow the same revision removing face-to-face physician time.

New way: For every added 30 minutes of prolonged services, you’ll report +99355 (Prolonged service in the office or further outpatient setting requiring direct patient contact further than the usual service; each added 30 minutes [List separately besides code for prolonged service])

Old way: + 99355 in 2011 was Prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual service; each additional 30 minutes [List separately besides code for prolonged physician service].

Append to Appropriate E/M Codes

You must keep in mind that prolonged services are additional codes that you have to report with suitable evaluation and management codes. You can report prolonged services after your gastroenterologist spends a total of 30 minutes beyond the typical times (as mentioned in the CPT® guidelines) for a specific E/M code.

As per CPT® 2012 revision, while the level of service of a particular code is met, still, the time involved with the patient goes beyond the highest level of that code grouping, you would use the prolonged service codes. You will report prolonged services in the outpatient setting or office with +99354. You can report every added 30 minutes of direct patient contact with +99355.

Discover Your Diagnostic Scope Coding Options to Safeguard Maximum Pay

Are you banking on 31575 for each of your diagnostic scope claim? You might be denying your practice up to $80 per claim, and in these times, you can’t manage to miss a dime. In case you can spot these significant terms for 31231 or 92511, then you can improve your claim’s bottom line. Read this expert medical coding article and know what ICD-9 and CPT codes apply.

You must grasp these scope fundamentals to ensure error-free claims.

ICD-9 and CPT Tip: Dismiss 92511 ‘Loser’ Myth

In case you’re like many ENT coders, you may not want to code 92511 (Nasopharyngoscopy with endoscope [separate procedure]) as you think it pays the minimum of the flexible scope codes. In reality, the code’s total value is in between the lower-paying 31575 (Laryngoscopy, flexible fiberoptic; diagnostic) and the higher-paying 31231 (Nasal endoscopy, diagnostic, unilateral or bilateral [separate procedure]).

With the current Medicare Physician Fee Schedule’s conversion factor of 34.0376, the codes’ relative value units and payments in ascending order include:

Surprise: Even though 92511 pays $27.57 more than 31575, and 31231 pays $79.99 more than the laryngoscopy code, the Correct Coding Initiative takes 31575 as the all-inclusive code. Code 31575 includes 92511 as well as 31231.

Check for 31575 Medical Necessity

Trace how far a flexible scope goes to see in case you’re in 31231, 92511 or 31575 territory. You must use 31231 for a scope of the nasal cavity and sinuses. 92511 denotes viewing the nasal cavity down the throat until the nasopharynx (the edge of the soft palate). Code 31575 is for a medically necessary scope that observes all the way down to the larynx.

Example: An ENT used topical lidocaine for anesthesia and executed flexible fiberoptic laryngoscopy through the right nostril. The procedure note specifies, "The nasopharynx, vallecula, epiglottis, sinuses as well as vocal cords were all visualized."

As the scope goes all the way into the larynx, 31575 might be accurate based on anatomy. You must use 31575 instead of 92511 only in case the note shows that scrutinizing this far was medically necessary. There has to be a main complaint and a history of a problem demanding viewing all the way down to the larynx.

In case, however, the ENT is simply looking for the condition of the nasopharynx, like for eustachian tube dysfunction (the eustachian tube terminate in the nasopharynx) or a mass in the nasopharynx, you would code 92511.

ICD-9 and CPT Expert Advice: Should You Make This ‘Rigid’ or ‘Flexible’ Distinction?

Even though you may think 31525 is meant for rigid laryngoscope and 31575 is for flexible laryngoscope -- end of story -- you need to keep in mind that the nasal exam (31231) may include a rigid scope. Consequently, you cannot assume a rigid scope is a laryngoscopy carried out under sedation.

ICD-9 and CPT Hint: ENTs do not execute rigid laryngoscopies in the office. Providers will schedule them for the OR on an outpatient basis. Thus, when the service is an office diagnostic procedure, a rigid scope simply means you should report a 31231.