2019 EAR, NOSE & THROAT (ENT) SURGERY MEDICARE ... · 2019 ear, nose & throat (ent) surgery medicare reimbursement coding guide effective january 1, 2019 physician3 hospital outpatient

2019 EAR, NOSE & THROAT (ENT) SURGERY MEDICARE REIMBURSEMENT CODING GUIDEEffective January 1, 2019

PHYSICIAN3 HOSPITAL OUTPATIENT4 ASC4

CPT CODE1/HCPCSCODE2

CODE DESCRIPTION

MEDICARE NAT’L AVG

APC AND APC DESCRIPTION


MEDICARE NAT’L AVGFACILITY

SETTINGNON-FACILITY

SETTING

CERVICAL RESECTION (MODIFIED RADICAL NECK DISSECTION)

38720 Cervical lymphadenectomy (complete) $1,391 NA

5093, Level 3 Breast/Lymphatic Surgery and Related Procedures

$7,449 N/A for ASC

38724 Cervical lymphadenectomy (modified radical neck dissection) $1,502 NA Inpatient only, not reimbursed for hospital

outpatient or ASC

PARATHYROID PROCEDURES

60500 Parathyroidectomy or exploration of parathyroid(s) $1.004 NA 5165, Level 5 ENT Procedures $4,424 $2,176

60502 Parathyroidectomy or exploration of parathyroid(s); re-exploration $1,344 NA 5165, Level 5 ENT

Procedures $4,424 N/A for ASC

60505Parathyroidectomy or exploration of parathyroid(s); with mediastinal exploration, sternal split or transthoracic approach

$1,447 NA Inpatient only, not reimbursed for hospital outpatient or ASC

PAROTID PROCEDURES

42410 Excision of parotid tumor or parotid gland; lateral lobe, without nerve dissection $645 NA 5165, Level 5 ENT

Procedures $4,424 $2,176

42415Excision of parotid tumor or parotid gland; lateral lobe, with dissection and preservation of facial nerve

$1,092 NA 5165, Level 5 ENT Procedures $4,424 $2,176

42420 Excision of parotid tumor or parotid gland; total, with dissection and preservation of facial nerve $1,227 NA 5165, Level 5 ENT


42425 Excision of parotid tumor or parotid gland; total, en bloc removal with sacrifice of facial nerve $864 NA 5165, Level 5 ENT


42426 Excision of parotid tumor or parotid gland; total, with unilateral radical neck dissection $1,399 NA Inpatient only, not reimbursed for hospital

outpatient or ASC

42440 Excision of submandibular (submaxillary) gland $426 NA 5165, Level 5 ENT Procedures $4,424 $2,176

42450 Excision of sublingual gland $370 $469 5165, Level 5 ENT Procedures $4,424 $2,176

42500 Plastic repair of salivary duct, sialodochoplasty; primary or simple $353 $450 5165, Level 5 ENT


42505 Plastic repair of salivary duct, sialodochoplasty; secondary or complicated $468 $576 5165, Level 5 ENT


Medicare National Average Rates and Allowables(Not Adjusted for Geography)



CODE DESCRIPTION





SETTINGNON-FACILITY

SETTING

PAROTID PROCEDURES CONT’D

42507 Parotid duct diversion, bilateral (Wilke type procedure) $522 NA 5165, Level 5 ENT


42509Parotid duct diversion, bilateral (Wilke type procedure); with excision of both submandibular glands

$864 NA 5165, Level 5 ENT Procedures $4,424 $2,176

42510Parotid duct diversion, bilateral (Wilke type procedure); with ligation of both submandibular (Wharton's) ducts

$64 NA 5164, Level 4 ENT Procedures $2,231 $969

THYROID PROCEDURES

60212Partial thyroid lobectomy, unilateral; with contralateral subtotal lobectomy, including isthmusectomy

$1,048 NA 5361, Level 1 Laparoscopy $4,596 $2,130

60225Total thyroid lobectomy, unilateral; with contralateral subtotal lobectomy, including isthmusectomy

$965 NA 5361, Level 1 Laparoscopy $4,596 $2,130

60240 Thyroidectomy, total or complete $954 NA 5361, Level 1 Laparoscopy $4,596 $2,130

60252 Thyroidectomy, total or subtotal for malignancy; with limited neck dissection $1,370 NA 5165, Level 5 ENT


60254 Thyroidectomy, total or subtotal for malignancy; with radical neck dissection $1,735 NA Inpatient only, not reimbursed for hospital

outpatient or ASC

60260Thyroidectomy, removal of all remaining thyroid tissue following previous removal of a portion of thyroid

$1,134 NA 5165, Level 5 ENT Procedures $4,424 N/A for

ASC

60270 Thyroidectomy, including substernal thyroid; sternal split or transthoracic approach $1,421 NA Inpatient only, not reimbursed for hospital

outpatient or ASC

60271 Thyroidectomy, including substernal thyroid; cervical approach $1,097 NA 5165, Level 5 ENT


TONSIL AND ADENOID PROCEDURES

42800 Biopsy; oropharynx $116 $162 5164, Level 4 ENT Procedures $2,231 $103

42804 Biopsy; nasopharynx, visible lesion, simple $118 $204 5164, Level 4 ENT Procedures $2,231 $969

42806 Biopsy; nasopharynx, survey for unknown primary lesion $137 $228 5164, Level 4 ENT

Procedures $2,231 $969

42809 Removal of foreign body from pharynx $127 $207 5735, Level 5 Minor Procedures $348 Pkg’d Pmt

42810 Excision branchial cleft cyst or vestige, confined to skin and subcutaneous tissues $296 $399 5164, Level 4 ENT


42815Excision branchial cleft cyst, vestige, or fistula, extending beneath subcutaneous tissues and/or into pharynx

$569 NA 5165, Level 5 ENT Procedures $4,424 $2,176

42820 Tonsillectomy and adenoidectomy; under age 12 $299 NA 5165, Level 5 ENT Procedures $4,424 $2,176

42821 Tonsillectomy and adenoidectomy; age 12 and over $311 NA 5164, Level 4 ENT Procedures $2,231 $969

42825 Tonsillectomy, primary or secondary; under age 12 $271 NA 5165, Level 5 ENT Procedures $4,424 $2,176

42826 Tonsillectomy, primary or secondary; age 12 and over $260 NA 5164, Level 4 ENT


42830 Adenoidectomy, primary; under age 12 $214 NA 5164, Level 4 ENT Procedures $2,231 $969

NOTES:

1. CPT copyright 2019 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. Centers for Medicare and Medicaid Services.

2. Healthcare Common Procedure Coding System. http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/Alpha-Numeric-HCPCS.html.

3. Centers for Medicare & Medicaid Services. Medicare Program; Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2019; Final Rule, Federal Register (83 Fed. Reg. No. 226 59452-60303) 42 CFR Parts 405, 410, 411, 414, 415, 425, and 495. (https://www.federalregister.gov/documents/2018/11/23/2018-24170/medicare-program-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other-revisions. Published November 23, 2018. See also the January 2019 release of the PFS Relative Value File RVU19A at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files-Items/RVU19A.html.

4. Centers for Medicare & Medicaid Services. Medicare Program: Changes to Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs. Final Rule, Federal Register (83 Fed. Reg. No. 225 58818-59179) 42 CFR Parts 416 and 419. https://www.gpo.gov/ fdsys/pkg/FR-2018-11-21/pdf/2018-24243.pdf. See also Medicare Program: Changes to Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Correction https://www.federalregister.gov/documents/2018/12/28/2018-28348/medicare-program-changes-to-hospital-outpatient-prospective-payment-and-ambulatory-surgical-center Published December 28, 2018. Addendum A, Addendum AA.

5. HCPCS II S-codes cannot be reported to Medicare. They are used only by non-Medicare payers, which cover and price them according to their own requirements.



CODE DESCRIPTION





SETTINGNON-FACILITY

SETTING

TONSIL AND ADENOID PROCEDURES CONT’D

42831 Adenoidectomy, primary; age 12 and over $232 NA 5164, Level 4 ENT Procedures $2,231 $969

42835 Adenoidectomy, secondary; under age 12 $199 NA 5164, Level 4 ENT Procedures $2,231 $969

42836 Adenoidectomy, secondary; age 12 and over $248 NA 5164, Level 4 ENT Procedures $2,231 $969

42842 Radical resection of tonsil, tonsillar pillars, and/or retromolar trigone; without closure $1,047 NA 5165, Level 5 ENT


42844Radical resection of tonsil, tonsillar pillars, and/or retromolar trigone; closure with local flap (eg, tongue, buccal)

$1,440 NA 5165, Level 5 ENT Procedures $4,424 N/A for

ASC

42860 Excision of tonsil tags $194 NA 5164, Level 4 ENT Procedures $2,231 $969

42870 Excision or destruction lingual tonsil, any method (separate procedure) $613 NA 5165, Level 5 ENT


42890 Limited pharyngectomy $1,487 NA 5165, Level 5 ENT Procedures $4,424 $2,176

ROBOTIC ASSISTANCE5

S2900 Surgical techniques requiring use of robotic surgical system N/A

HOSPITAL INPATIENT PROCEDURE CODING FOR EAR, NOSE AND THROAT SURGERY

ICD-10-PCS procedure codes1 are used by hospitals to report surgeries and procedures performed in the inpatient setting.

All ICD-10-PCS codes have seven digits, each digit representing a specific character associated with procedures. Code assignment in ICD-10-PCS is a process of “constructing” the code by selecting values from a code table for each of the seven standard characters. Key characters are discussed below.

CHARACTER DESCRIPTION

3: Root Operation

The two main root operations for removal of tissue are B-Excision and T-Resection. By definition, B-Excision involves removing a portion of the body part and T-Resection involves removing the entire body part.2 For example, partial parathyroidectomy uses B-Excision. Because modified radical neck dissection involves removing all lymph chains in the region, this procedure uses T-Resection.

Note that physicians may use these terms more broadly. It’s the coder’s responsibility to determine what the physician’s documentation equates to in terms of ICD-10-PCS definitions. The physician is not expected to document using ICD-10-PCS code descriptions, and the coder is not required to query the physician in these circumstances.3

4: Body PartThis character names the specific site of the procedure. Except as noted, two codes are assigned for a bilateral procedure, eg, for a bilateral modified neck dissection, use one code for right neck and one code for left neck.

5: Approach

Different codes are constructed depending on the approach: 0-Open involves an open incision to directly expose the surgical site 3-Percutaneous involves advancing instruments to the surgical site through body layers, typically under imaging. 4-Percutaneous Endoscopic involves advancing an endoscope through body layers to perform the procedure. X-External is used for procedures performed within an orifice on structures that are visible without instrumentation.4

7: Qualifier

Qualifiers add further information to the code. Qualifier X-Diagnostic is used to identify biopsies.5 For therapeutic procedures, the most common qualifier is Z-No Qualifier. This means that the same code can be used for both biopsy and removal of the same lung tumor, with only the different qualifier values identifying if the procedure was a diagnostic biopsy or a therapeutic excision.

PIC

ICD-10-PCS PROCEDURE CODE PROCEDURE CODE DESCRIPTION


07T10ZZ Resection of right neck lymphatic, open approach

07T20ZZ Resection of left neck lymphatic, open approach

07T14ZZ Resection of right neck lymphatic, percutaneous endoscopic approach

07T24ZZ Resection of left neck lymphatic, percutaneous endoscopic approach


> BIOPSY OF PARATHYROID GLAND

0GBR0ZX Excision of parathyroid gland, open approach, diagnostic

0GBR3ZX Excision of parathyroid gland, percutaneous approach, diagnostic

0GBR4ZX Excision of parathyroid gland, percutaneous endoscopic approach, diagnostic

> PARTIAL PARATHYROIDECTOMY

0GBR0ZZ Excision of parathyroid gland, open approach

0GBR4ZZ Excision of parathyroid gland, percutaneous endoscopic approach

> COMPLETE PARATHYROIDECTOMY

0GTR0ZZ Resection of parathyroid gland, open approach

0GTR4ZZ Resection of parathyroid gland, percutaneous endoscopic approach

PAROTID PROCEDURES

> PARTIAL PAROTIDECTOMY

0CB80ZZ Excision of right parotid gland, open approach

0CB90ZZ Excision of left parotid gland, open approach

> COMPLETE PAROTIDECTOMY

0CT80ZZ Resection of right parotid gland, open approach

0CT90ZZ Resection of left parotid gland, open approach

THYROID PROCEDURES

> BIOPSY OF THYROID GLAND

0GBG0ZX Excision of left thyroid gland lobe, open approach, diagnostic

0GBH0ZX Excision of right thyroid gland lobe, open approach, diagnostic

0GBG3ZX Excision of left thyroid gland lobe, percutaneous approach, diagnostic

0GBH3ZX Excision of right thyroid gland lobe, percutaneous approach, diagnostic

0GBG4ZX Excision of left thyroid gland lobe, percutaneous endoscopic approach, diagnostic

0GBH4ZX Excision of right thyroid gland lobe, percutaneous endoscopic approach, diagnostic

> EXCISION OF THYROID LESION, PARTIAL THYROIDECTOMY

0GBG0ZZ Excision of left thyroid gland lobe, open approach

0GBH0ZZ Excision of right thyroid gland lobe, open approach

0GBG3ZZ Excision of left thyroid gland lobe, percutaneous approach

0GBH3ZZ Excision of right thyroid gland lobe, percutaneous approach

0GBG4ZZ Excision of left thyroid gland lobe, percutaneous endoscopic approach

0GBH4ZZ Excision of right thyroid gland lobe, percutaneous endoscopic approach

> THYROID LOBECTOMY

0GTG0ZZ Resection of left thyroid gland lobe, open approach

0GTH0ZZ Resection of right thyroid gland lobe, open approach

ICD-10-PCS PROCEDURE CODE PROCEDURE CODE DESCRIPTION

0GTG4ZZ Resection of left thyroid gland lobe, percutaneous endoscopic approach

0GTH4ZZ Resection of right thyroid gland lobe, percutaneous endoscopic approach

> COMPLETE THYROIDECTOMY

0GTK0ZZ Resection of thyroid gland, open approach

0GTK4ZZ Resection of thyroid gland, percutaneous endoscopic approach

TONSIL AND ADENOID PROCEDURES

> TONSILLECTOMY

0CTPXZZ Resection of tonsils, external approach

> ADENOIDECTOMY

0CTQXZZ Resection of adenoids, external approach

> EXCISION OF TONSIL TAG OR OTHER LESION OF TONSIL

0CBPXZZ Excision of tonsils, external approach

> EXCISION OF LINGUAL TONSIL

0CB7XZZ Excision of tongue, external approach

ROBOTIC ASSISTANCE6

8E090CZ Robotic assisted procedure of head and neck region, open approach

8E093CZ Robotic assisted procedure of head and neck region, percutaneous approach

8E094CZ Robotic assisted procedure of head and neck region, percutaneous endoscopic approach

8E09XCZ Robotic assisted procedure of head and neck region, external approach

Notes:

1. ICD-10-CM: Department of Health and Human Services, Centers for Medicare & Medicaid Services. International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS). http://www.cms.hhs.gov/Medicare/Coding/ICD10/2016-ICD-10-PCS-and-GEMs.html

2. CMS ICD-10-PCS Reference Manual 2019. See also ICD-10-PCS Procedure Coding System (ICD-10-PCS) 2016 Tables and Index, ICD-10-PCS Definitions appendix (0 3: Medical and Surgical - Operation), root operations Excision and Resection

3. 2019 ICD-10-PCS Official Guidelines for Coding and Reporting (Procedure), A11

4. AHA ICD-10-CM and ICD-10-PCS Coding Handbook with Answers 2016, p.75

5. AHA ICD-10-CM and ICD-10-PCS Coding Handbook with Answers 2016, p.92

6. Codes for robotic assistance are assigned separately in addition to the primary procedure code.

HOSPITAL INPATIENT DRGS FOR EAR, NOSE AND THROAT SURGERYDRG Assignment FY2019—effective October 1, 2018

Under Medicare’s MS-DRG methodology for hospital inpatient payment, each inpatient stay is assigned to one of about 750 diagnosis-related groups, based on the ICD-10 codes assigned to the diagnoses and procedures. Each MS-DRG has a relative weight that is then converted to a flat payment amount. Implanted devices are typically included in the flat payment and are not paid separately. Only one MS-DRG is assigned for each inpatient stay, regardless of the number of procedures performed. MS-DRGs shown are those typically assigned to the following scenarios when the patient is admitted specifically for the procedure.

MS-DRG1 MS-DRG TITLE1,2 FY 2019 RELATIVE

WEIGHT1

FY 2019 GEOMETRIC MEAN LENGTH OF STAY1

FY 2019 SUBJECT TO PACT1,3

FY 2019 MEDICARE NATIONAL AVERAGE4


129Major Head and Neck Procedures W CC/MCC or Major Device

2.4310 3.7 No $14,842

130 Major Head and Neck Procedures W/O CC/MCC 1.4912 2.3 No $9,015


625Thyroid, Parathyroid and Thyroglossal Procedures W MCC

2.7833 4.8 No $16,993

626Thyroid, Parathyroid and Thyroglossal Procedures W CC

1.6106 2.5 No $9,833

627Thyroid, Parathyroid and Thyroglossal Procedures W/O CC/MCC

1.0850 1.4 No $6,624

PAROTID PROCEDURES

139 Salivary Gland Procedures 1.1604 2.1 No $7,085

THYROID PROCEDURES5

625Thyroid, Parathyroid and Thyroglossal Procedures W MCC

2.7833 4.8 No $16,993

626Thyroid, Parathyroid and Thyroglossal Procedures W CC

1.6106 2.5 No $9,833

627Thyroid, Parathyroid and Thyroglossal Procedures W/O CC/MCC

1.0850 1.4 No $6,624

TONSIL AND ADENOID PROCEDURES6

133Other Ear, Nose, Mouth and Throat OR Procedures W CC/MCC

2,0986 4.0 No $12,813

134Other Ear, Nose, Mouth and Throat OR Procedures W/O CC/MCC

1.1987 2.0 No $7,319

Medtronic provides this information for your convenience only. It does not constitute legal advice or a recommendation regarding clinical practice. Information provided is gathered from third-party sources and is subject to change without notice due to frequently changing laws, rules and regulations. The provider has the responsibility to determine medical necessity and to submit appropriate codes and charges for care provided. Medtronic makes no guarantee that the use of this information will prevent differences of opinion or disputes with Medicare or other payers as to the correct form of billing or the amount that will be paid to providers of service. Please contact your Medicare contractor, other payers, reimbursement specialists and/or legal counsel for interpretation of coding, coverage and payment policies. This document provides assistance for FDA approved or cleared indications. Where reimbursement is sought for use of a product that may be inconsistent with, or not expressly specified in, the FDA cleared or approved labeling (e.g., instructions for use, operator’s manual or package insert), consult with your billing advisors or payers on handling such billing issues. Some payers may have policies that make it inappropriate to submit claims for such items or related service.

CPT® is a registered trademark of the American Medical Association. This information is for educational purposes only and is not intended to serve as reimbursement advice. It is the responsibility of the provider to select the codes that most accurately reflect the patient’s condition and procedures performed, and to consult with each patient’s health plan for appropriate reporting of each procedure. In all cases, services must be medically necessary, actually performed and appropriately documented.

© 2019 Medtronic. All rights reserved. Medtronic, Medtronic logo and Further, Together are trademarks of Medtronic. ™* Third party brands are trademarks of their respective owners. All other brands are trademarks of a Medtronic company. 05/2019 US190448

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Notes:

1. Centers for Medicare & Medicaid Services. Medicare Program: Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year 2019 Rates; Quality Reporting Requirements for Specific Providers; Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs (Promoting Interoperability Programs) Requirements for Eligible Hospitals, Critical Access Hospitals, and Eligible Professionals; Medicare Cost Reporting Requirements; and Physician Certification and Recertification of Claims. Final Rule, Federal Register (83 Fed. Reg. No. 160 41144-417842) 42 CFR Parts 412, 413, 424, and 495 https://www.gpo.gov/fdsys/pkg/FR-2018-08-17/pdf/2018-16766.pdf. Published August 17, 2018.

2. W MCC in MS-DRG titles refers to secondary diagnosis codes that are designated as major complications or comorbidities. MS-DRGs W MCC have at least one major secondary complication or comorbidity. Similarly, W CC in MS-DRG titles refers to secondary diagnosis codes designated as other (non-major) complications or comorbidities, and MS-DRGs W CC have at least one other (non-major) secondary complication or comorbidity. MS-DRGs W/O CC/MCCs have no secondary diagnoses that are designated as complications or comorbidities, major or otherwise. Note that some secondary diagnoses are only designated as CCs or MCCs when the conditions were present on admission, and do not count as CCs or MCCs when the conditions are acquired in the hospital during the stay.

3. Post-Acute Care Transfer (PACT) status refers to selected DRGs in which payment to the hospital may be reduced when the patient is discharged by being transferred out. The DRGs impacted are those marked “Yes” and the patient must be transferred out before the geometric mean length of stay to certain post-acute care providers, including rehabilitation hospitals, long term care hospitals, skilled nursing facilities, or to home under the care of a home health agency. When these conditions are met, the DRG payment is converted to a per diem and payment is made as double the per diem rate for the first day plus the per diem rate for each remaining day up to the full DRG payment.

4. Payment is based on the average standardized operating amount ($5646.08) plus the capital standard amount ($459.41). Centers for Medicare & Medicaid Services. Medicare Program: Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year 2019 Rates; Quality Reporting Requirements for Specific Providers; Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs (Promoting Interoperability Programs) Requirements for Eligible Hospitals, Critical Access Hospitals, and Eligible Professionals; Medicare Cost Reporting Requirements; and Physician Certification and Recertification of Claims. Final Rule, Federal Register (83 Fed. Reg. No. 160 41144-417842) 42 CFR Parts 412, 413, 424, and 495 https://www.gpo.gov/fdsys/pkg/FR-2018-08-17/pdf/2018-16766.pdf. Published August 17, 2018

5. Only open thyroid biopsies group to DRGs 625-627. Percutaneous and percutaneous endoscopic biopsies are not designated as significant operating room procedures for the purpose of DRG assignment. If they are the only procedures performed, the case groups to a medical DRG based on the principal diagnosis code.

6. Code 0CB7XZZ for excision of lingual tonsil groups to DRGs 137-138 when it is the only procedure performed.

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2019 EAR, NOSE & THROAT (ENT) SURGERY MEDICARE ... · 2019 ear, nose & throat (ent) surgery medicare reimbursement coding guide effective january 1, 2019 physician3 hospital outpatient