CODING 2016 SA Soc ORL-HNS Conference Johannesburg
Coding: What you need to know CODES COMMENTS COMMENTS New Codes Tiered Codes Discharge Code Rule G Strobe and Flexible Scope STR / NSR Cosmetic vs Functional Unbundling Guidelines
Coding: What you need to know CODES COMMENTS COMMENTS New Codes 2016: not all funds Can use old codes Tiered Codes Can use same fee 0193 not recognised Discharge Code 0176 < 30 mins 0177 > 30 mins Rule G 30 days (10 for grommets) Routine cases 0 for scopes / trachy Comorbid not routine Strobe and Flexible Scope Reject repeated use 1018 + 1130 -- avoid STR / NSR Cosmetic vs Functional 1085 = 1087 + 1022 Cosmetic clearly identified Unbundling Check Descriptors Medical advisors may be wrong Guidelines Funds refer to SAMA often Challenge 0145 + 0109? Funds don t follow SAMA tiers nor equal rand unit value for ops and consults
Descriptors and Guidelines 1036 Endoscopic ethmoid surgery: Bilateral 245 This item applies to surgery of the ethmoids only and may be combined with the items for surgery to the frontal, antral and sphenoid sinuses and/or surgery to the septum, turbinates and external nose (modifier 0005 applies) Modifier 0069 Endoscopic instruments add 10% of the fee of the procedure 4892 Endoscopy: Sinus/nasal, with partial, anterior ethmoidectomy 73.4 This item may not be combined with 1035 (ipsilateral) nor 1036 Modifier 0069 Endoscopic instruments add 10% of the fee of the procedure This item may be combined with 1035 when performed on contralateral side Current codes used: 1036 (for bilateral), 1035 (for unilateral) 1033 Removal of multiple polyps in hospital under general anaesthetic 90 Item 1033 - Removal of multiple polyps in hospital under general anaesthetic (unilateral), may not be charged routinely in conjunction with item 1035 nor item 1036 nor other sino-nasal items. Item 1033 - may be used in conjunction with item1035 and item 1036 and other sino-nasal items for cases with significant polyposis. Modifier 0005 is applicable Modifier 0069 - Endoscopic instruments add 10% of the fee of the procedure
1105 Removal of adenoids <12 40 Modifier 0005 is applicable to item 1052 - Instrumental examination of the nasopharynx including biopsy under general anaesthetic, when used in conjunction with adenoidectomy (item 1105) Modifier 0005 is applicable if a tonsillectomy and an adenoidectomy are performed at the same session Diathermy to nose or pharynx item 1039 may not be used routinely in conjunction with item 1105 Item 1039 may be used for excessive bleeding or adenoid remnant cautery Use item 1105 for >12 (new code not accepted). Recommend 55.5 units
ENT 80% Basket (Change Units only to match CPT4 relativity) CODE DESCRIPTOR CROSSWALK CPT4 RVU CURRENT UNITS 2016 UNITS AT 10X CHANGE (DECREASE) 1069 PROOF PUNCTURE 31000 3.16 35 31.6 (3.4) (9.7%) 1052 INSTRUMENTAL EXAMINATION NASOPHARYNX 42806 4.05 50 40.5 (9.5) (19%) 1030 ENDOSCOPIC TURBINECTOMY LASER OR MICRODEBRIDER 31240 5.78 90 57.8 (32.2) (35.7%) 3245 FUNCTIONAL RECONSTRUCTION 69631 27.05 277 270.5 (6.5) (2.3%) TYMPANIC MEMBRANE 1101 TONSILLECTOMY <12YRS 42825 (<12yrs) 7.64 75 76.4 1.4 1.8% 1105 ADENOIDECTOMY <12YRS 42835 5.9 40 59 19 47.5% 1087 SUBTOTAL RECONSTRUCTION 30400 30.58 210 305.8 95.8 45.6% 1022 FUNCTIONAL RECONSTRUCTION 30520 18.91 121.2 189.1 67.9 56% NASAL SEPTUM 3237 EXPLORATORY TYMPANOTOMY 69440 21.12 158.9 211.2 52.3 32.9%
Confirmation MedCodeLink, Dalena Coetzee 2016 RVUs < 2014 RVUs CODE DESCRIPTOR CROSSWALK CPT4 RVU 2014 RVU 2016 1069 DPP (sinus washout) 31000 3.16 3.04 1052 PNS (post nasal )EXAM 42806 4.05 3.83 1030 ENDOSCOPIC TURBINECTOMY 31240 4.79 4.63 3245 FUNCTIONAL RECONSTRUCTION TYMPANIC MEMBRANE 69631 27.05 25.46 1101 TONSILLECTOMY <12YRS 42825<12yrs 7.98 7.58 1105 ADENOIDECTOMY <12YRS 42835 5.9 5.6 1087 SUBTOTAL RECONSTRUCTION 30400 30.58 28.68 1022 SEPTUM RECONSTRUCTION 30520 18.91 17.78 3237 EXPLORATORY TYMPANOTOMY 69440 21.12 19.81
New code Sphenopalatine artery ligation/cautery CODE DESCRIPTOR CROSSWALK RVU CURRENT 2016 UNITS AT CHANGE CCSA 2016 CPT4 UNITS 10X NEW CODE SPHENOPALATINE ARTERY LIGATION/CAUTERY 31238 5.83 N/A N/A 4.87