2018 EAR, NOSE & THROAT (ENT) SURGERY MEDICARE REIMBURSEMENT CODING GUIDE

Transcription

1 2018 EAR, NOSE & THROAT (ENT) SURGERY REIMBURSEMENT CODING GUIDE Effective January 1, 2018 Medicare National Average Rates and Allowables (Not Adjusted for Geography) PHYSICIAN 3 HOSPITAL OUTPATIENT 4 4 CPT CODE 1 / HCPCS CODE 2 CODE DESCRIPTION CF=$ FACILITY CERVICAL RESECTION (MODIFIED RADICAL NECK DISSECTION) Cervical lymphadenectomy (complete) $1,382 NA Cervical lymphadenectomy (modified radical neck dissection) PARATHYROID PROCEDURES $1,490 NA Parathyroidectomy or exploration of parathyroid(s) $998 NA Parathyroidectomy or exploration of parathyroid(s); re-exploration Parathyroidectomy or exploration of parathyroid(s); with mediastinal exploration, sternal split or transthoracic approach PAROTID PROCEDURES Excision of parotid tumor or parotid gland; lateral lobe, without nerve dissection Excision of parotid tumor or parotid gland; lateral lobe, with dissection and preservation of facial nerve Excision of parotid tumor or parotid gland; total, with dissection and preservation of facial nerve Excision of parotid tumor or parotid gland; total, en bloc removal with sacrifice of facial nerve Excision of parotid tumor or parotid gland; total, with unilateral radical neck dissection $1,334 NA $1,431 NA $639 NA $1,082 NA $1,216 NA $859 NA $1,385 NA NON-FACILITY APC AND APC DESCRIPTION 5093, Level 3 Breast/Lymphatic Surgery and Related $7,388 outpatient or outpatient or outpatient or Excision of submandibular (submaxillary) gland $423 NA Excision of sublingual gland $369 $ Plastic repair of salivary duct, sialodochoplasty; primary or simple Plastic repair of salivary duct, sialodochoplasty; secondary or complicated $352 $445 $465 $570

2 PHYSICIAN 3 HOSPITAL OUTPATIENT 4 4 CPT CODE 1 / HCPCS CODE CODE DESCRIPTION PAROTID PROCEDURES CONT D Parotid duct diversion, bilateral (Wilke type procedure) Parotid duct diversion, bilateral (Wilke type procedure); with excision of both submandibular glands Parotid duct diversion, bilateral (Wilke type procedure); with ligation of both submandibular (Wharton's) ducts THYROID PROCEDURES Partial thyroid lobectomy, unilateral; with contralateral subtotal lobectomy, including isthmusectomy Total thyroid lobectomy, unilateral; with contralateral subtotal lobectomy, including isthmusectomy CF=$ FACILITY $525 NA $865 NA $643 NA $1,070 NA $959 NA Thyroidectomy, total or complete $948 NA Thyroidectomy, total or subtotal for malignancy; with limited neck dissection Thyroidectomy, total or subtotal for malignancy; with radical neck dissection Thyroidectomy, removal of all remaining thyroid tissue following previous removal of a portion of thyroid Thyroidectomy, including substernal thyroid; sternal split or transthoracic approach Thyroidectomy, including substernal thyroid; cervical approach TONSIL AND ADENOID PROCEDURES $1,363 NA $1,719 NA $1,126 NA $1,413 NA $1,090 NA NON-FACILITY APC AND APC DESCRIPTION 5361, Level 1 Laparoscopy 5361, Level 1 Laparoscopy 5361, Level 1 Laparoscopy $4,488 $2,142 $4,488 $2,142 $4,488 $2,142 outpatient or outpatient or Biopsy; oropharynx $115 $ Biopsy; nasopharynx, visible lesion, simple $116 $ Biopsy; nasopharynx, survey for unknown primary lesion $136 $ Removal of foreign body from pharynx $126 $ Excision branchial cleft cyst or vestige, confined to skin and subcutaneous tissues Excision branchial cleft cyst, vestige, or fistula, extending beneath subcutaneous tissues and/or into pharynx $297 $397 $572 NA Tonsillectomy and adenoidectomy; under age 12 $297 NA Tonsillectomy and adenoidectomy; age 12 and over $308 NA Tonsillectomy, primary or secondary; under age 12 $268 NA Tonsillectomy, primary or secondary; age 12 and over $258 NA Adenoidectomy, primary; under age 12 $212 NA 5735, Level 5 Minor $2,199 $102 $330 Pkg d Pmt

3 PHYSICIAN 3 HOSPITAL OUTPATIENT 4 4 CPT CODE 1 / HCPCS CODE 2 CODE DESCRIPTION CF=$ FACILITY NON-FACILITY APC AND APC DESCRIPTION TONSIL AND ADENOID PROCEDURES CONT D Adenoidectomy, primary; age 12 and over $229 NA Adenoidectomy, secondary; under age 12 $197 NA Adenoidectomy, secondary; age 12 and over $247 NA Radical resection of tonsil, tonsillar pillars, and/or retromolar trigone; without closure Radical resection of tonsil, tonsillar pillars, and/ or retromolar trigone; closure with local flap (eg, tongue, buccal) $1,047 NA $1,441 NA Excision of tonsil tags $192 NA Excision or destruction lingual tonsil, any method (separate procedure) $615 NA Limited pharyngectomy $1,488 NA S2900 ROBOTIC ASSISTANCE 5 Surgical techniques requiring use of robotic surgical system N/A NOTES: 1. CPT copyright 2015 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. 2. Centers for Medicare and Medicaid Services. Healthcare Common Procedure Coding System. HCPCSReleaseCodeSets/Alpha-Numeric-HCPCS.html. 3. Centers for Medicare & Medicaid Services. Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2018 Final Rule; 82 Fed. Reg ; : Published November 15, See also the January 2018 release of the PFS Relative Value File RVU18A at PhysicianFeeSched/PFS-Relative-Value-Files.html. Final payment to the physician is adjusted by the Geographic Practice Cost Indices (GPCI). Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the payment amount shown. 4. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems. Final Rule: 82 Fed. Reg ; [CMS 1678-FC]: medicare-program-hospital-outpatient-prospective-payment-and-ambulatory-surgical-center-payment. Published November 13, Payment is adjusted by the wage index for each hospital or s specific geographic locality, so payment will vary from the national average Medicare payment levels displayed. Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the national average payment amount shown. 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.

4 HOSPITAL INPATIENT PROCEDURE CODING FOR EAR, NOSE AND THROAT SURGERY PIC ICD-10-PCS procedure codes 1 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 3: Root Operation 4: Body Part 5: Approach 7: Qualifier DESCRIPTION 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 This 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. 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 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.

5 ICD-10-PCS PROCEDURE CODE PROCEDURE CODE DESCRIPTION CERVICAL RESECTION (MODIFIED RADICAL NECK DISSECTION) 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 PARATHYROID PROCEDURES > 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 0CB90ZZ 0CT80ZZ 0CT90ZZ > COMPLETE PAROTIDECTOMY THYROID PROCEDURES > BIOPSY OF THYROID GLAND Excision of right parotid gland, open approach Excision of left parotid gland, open approach Resection of right parotid gland, open approach Resection of left parotid gland, open approach 0GBG0ZX 0GBH0ZX 0GBG3ZX 0GBH3ZX 0GBG4ZX 0GBH4ZX 0GBG0ZZ 0GBH0ZZ 0GBG3ZZ 0GBH3ZZ 0GBG4ZZ 0GBH4ZZ 0GTG0ZZ 0GTH0ZZ Excision of left thyroid gland lobe, open approach, diagnostic Excision of right thyroid gland lobe, open approach, diagnostic Excision of left thyroid gland lobe, percutaneous approach, diagnostic Excision of right thyroid gland lobe, percutaneous approach, diagnostic Excision of left thyroid gland lobe, percutaneous endoscopic approach, diagnostic Excision of right thyroid gland lobe, percutaneous endoscopic approach, diagnostic > EXCISION OF THYROID LESION, PARTIAL THYROIDECTOMY Excision of left thyroid gland lobe, open approach Excision of right thyroid gland lobe, open approach Excision of left thyroid gland lobe, percutaneous approach Excision of right thyroid gland lobe, percutaneous approach Excision of left thyroid gland lobe, percutaneous endoscopic approach Excision of right thyroid gland lobe, percutaneous endoscopic approach > THYROID LOBECTOMY Resection of left thyroid gland lobe, open approach Resection of right thyroid gland lobe, open approach

6 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 0CTQXZZ 0CBPXZZ 0CB7XZZ 8E090CZ 8E093CZ 8E094CZ 8E09XCZ Resection of tonsils, external approach > ADENOIDECTOMY Resection of adenoids, external approach > EXCISION OF TONSIL TAG OR OTHER LESION OF TONSIL Excision of tonsils, external approach > EXCISION OF LINGUAL TONSIL Excision of tongue, external approach ROBOTIC ASSISTANCE 6 Robotic assisted procedure of head and neck region, open approach Robotic assisted procedure of head and neck region, percutaneous approach Robotic assisted procedure of head and neck region, percutaneous endoscopic approach 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) CMS ICD-10-PCS Reference Manual 2016, p 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 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 AHA ICD-10-CM and ICD-10-PCS Coding Handbook with Answers 2016, p Codes for robotic assistance are assigned separately in addition to the primary procedure code.

7 HOSPITAL INPATIENT DRGS FOR EAR, NOSE AND THROAT SURGERY DRG Assignment FY2018 effective January 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. FY 2018 MS- FY 2018 RELATIVE MS-DRG TITLE DRG 1,2 GEOMETRIC MEAN 1 WEIGHT 1 LENGTH OF STAY 1 CERVICAL RESECTION (MODIFIED RADICAL NECK DISSECTION) FY 2018 SUBJECT TO PACT 1,3 FY 2018 NATIONAL AVERAGE Major Head and Neck W CC/MCC or Major Device No $13, Major Head and Neck W/O CC/MCC No $8,665 PARATHYROID PROCEDURES W MCC W CC W/O CC/MCC PAROTID PROCEDURES No $16, No $9, No $6, Salivary Gland No $6,725 THYROID PROCEDURES W MCC W CC W/O CC/MCC TONSIL AND ADENOID PROCEDURES 6 Other Ear, Nose, Mouth and Throat OR W CC/MCC Other Ear, Nose, Mouth and Throat OR W/O CC/MCC No $16, No $9, No $6, No $11, No $6,995

8 Notes: 1. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Changes and FY2018 Rates Final Rule, 81 Fed. Reg : 14/pdf/ pdf. Published August 14, 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 ($5,461.19) plus the capital standard amount ($453.95). Centers for Medicare & Medicaid Services. Medicare Program: Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Changes and FY2018 Rates; Correction, 82 Fed. Reg Tables 1A-1E. pdf/ pdf. Published October 4, The payment rate shown is the standardized amounts for facilities with a wage index greater than one. The average standard amounts shown also assume facilities receive the full quality update. The payment will also be adjusted by the Wage Index for specific geographic locality. Therefore, payment for a specific hospital will vary from the stated Medicare national average payment levels shown. Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the national average payment amount shown. 5. Only open thyroid biopsies group to DRGs 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 when it is the only procedure performed. This information is taken from the materials published by the Centers for Medicare and Medicaid Services and the American Medical Association and may be helpful to providers in staying up to date on coding and billing of services. This information cannot guarantee coverage or reimbursement, and Medtronic makes no other representations as to selecting codes for procedures or compliance with any other billing protocols or prerequisites. As with all claims, providers are responsible for exercising their independent clinical judgment in selecting the codes that most accurately reflect the patient s condition and procedures performed for a patient. Providers should refer to current, complete, and authoritative publications such as AMA HCPCS Level II, CPT publications or insurer policies for selecting codes based on the care rendered to an individual patient, and may wish to contact individual carriers, fiscal intermediaries, or other third-party payers as needed. 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 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. 03/2018 US Medtronic 5920 Longbow Drive Boulder, CO USA T: (303) US: (800) medtronic.com