ENT Coding: Does Your Nose Know When You Are Coding It Correctly?

Transcription

1 ENT Coding: Does Your Nose Know When You Are Coding It Correctly? Presented to: AAPC Annual Meeting Orlando, Florida April 16, 2013 Presented by: Kim Pollock, RN, MBA, CPC

2 Kim Pollock, RN, MBA, CPC Consultant and Speaker For over thirteen years, Kim Pollock has helped large group practices, as well as academic and solo practices, improve collections and efficiency. She is expert at auditing coding and documentation for all subspecialties of otolaryngology. She knows how to apply reimbursement principles to ensure otolaryngologists are paid accurately. She has over thirty years of healthcare experience working for and with otolaryngologists. Ms. Pollock understands the complexity of coding and reimbursement issues specific to otolaryngologists both from a clinical perspective and from a payor side. She is an expert in analyzing chart documentation and in reengineering practices to enhance the reimbursement process. She presents seminars and workshops for physicians and their staff on behalf of the American Academy of Otolaryngology-Head and Neck Surgery (AAOHNS), the American Association of Neurological Surgeons and the American Society of Plastic Surgeons. Ms. Pollock has also conducted programs for the American Academy of Professional Coders, the North American Spine Society, the American Neurotology Society and the Congress of Neurological Surgeons. Based on her previous years of administrative experience, Ms. Pollock has a unique understanding of the challenges facing academic medicine both clinically and organizationally. She has served as the Administrator of the Department of Otorhinolaryngology as well as Associate Vice President of Cancer Programs at the University of Texas Southwestern Medical Center in Dallas. Ms. Pollock was the representative for the AAO-HNS on the clinical practice expert paneltechnical group (CPEP-TEG) convened by CMS (formerly HCFA) to redetermine the practice expense portion of RBRVS. She served two terms on the Board of Directors for the Society of Otorhinolaryngology and Head-Neck Nurses, Inc. (SOHN) and has served on the Board for the Ear, Nose and Throat Nursing Foundation. Ms. Pollock is the recipient of the prestigious Presidential Citation Award from the SOHN as well as an Honor Award from the AAOHNS. Ms. Pollock holds a Masters of Business Administration Degree as well as a Bachelors of Science Degree in Nursing. She is also a certified coder through the AAPC. KZA Disclaimer This manual is not intended to provide legal advice to physicians and their staffs. If you have specific questions regarding the permissibility of your billing or other practices, we recommend that you consult legal counsel directly for assistance in evaluating any legal, regulatory or compliance issues regarding these matters. In the event that you choose to consult with outside legal counsel, KZA is available to work with such counsel, as appropriate, to meet your needs. CPT five digit codes, nomenclature and other data are copyright 2011 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein. 2

3 Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service CPT Says: It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient's condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier 57. For significant, separately identifiable non-e/m services, see modifier 59. Tips Used to indicate an E&M service is significant and separately identifiable on the same day as a minor procedure. Note, this modifier is not used to report an E&M service that resulted in decision to perform surgery. (Medicare defines this as a procedure with a global period of 0 or 10 days). Attach modifier 25 to the E&M service on same day as minor procedure. Allows significant, separately identifiable E&M service to be reimbursed on the same day as a minor procedure. Different diagnosis not required. Don t forget: The global surgical package includes the E&M on the same day of a minor procedure unless there is significant, separately identifiable reason and documentation for the service. That s when you append modifier 25 to the E&M code. Example Example: New patient E&M for evaluation of hoarseness on same day as a flexible fiberoptic laryngoscopy (9920x-25 and 31575). 3

4 Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service The OIG says that modifier 25 is misused and overpayments have resulted. CMS carriers are auditing so are private payors. ALERT: Medicare Part B News (11/5/12) says otolaryngologists billed an E&M visit ( ) appended with modifier 25 on 42.3% of 2011 Medicare claims. How often did you? REMEMBER: All procedure codes have an inherent E&M component. Ask yourself: What have I done that goes above and beyond a minimal E&M service that is included in that procedure code? And, does my documentation support that additional work and effort? Scenario 1. New patient, 67 year old female, is seen for hoarseness. In additional to your usual exam, you also do a flexible fiberoptic laryngoscopy. You write an E&M note and a separate procedure note. 2. Established patient you saw two weeks ago returns for scheduled excision of skin lesions. You write an E&M note and a separate procedure note. 3. Established patient returns for follow-up of hoarseness after two weeks of voice rest. Her mirror exam is now within normal limits. However, she now complains of green drainage from her nose so you do a nasal endoscopy and diagnosis her with acute maxillary sinusitis and prescribe an antibiotic. You write an E&M note and a separate procedure note. 4. Established patient returns for follow-up of hoarseness after two weeks of voice rest. You do a flexible fiberoptic laryngoscopy on her and her exam is within normal limits. You ask her to return prn. You write an E&M note and a separate procedure note. 5. Established patient returns for follow-up of hoarseness after two weeks of voice rest. You do a flexible fiberoptic laryngoscopy on her and her exam is worse. You now prescribe speech therapy for her and ask her to return in 4 weeks. You write an E&M note and a separate procedure note. Code(s) 4

5 Modifier 57: Decision for Surgery CPT Says: An evaluation and management service that resulted in the initial decision to perform the surgery may be identified by adding modifier 57 to the appropriate level of E/M service. Tips Used to reflect a surgery decision-making E&M service was performed on the day before or the day of a major procedure. (Medicare defines this as a procedure with a global period of 90 days.) Append modifier 57 to the E&M service same day or day before major, or unplanned, procedure. Allows payment for the E&M as well as the procedure. This typically is the decision making E&M for an emergent or unplanned major procedure. Different diagnosis not required. Do not use modifier 57 on an E&M code to report a routine pre-op visit or an H&P on the day of the elective procedure. Examples You are asked to see a non-medicare patient in the emergency room at the request of Dr. ER to evaluate a deep neck abscess. You perform the consultation service (9924x-57) and take the patient to the operating room for I&D (21501). You admit a Medicare patient from your office to the hospital to treat a deep neck abscess with IV antibiotics and subsequently see the patient in the hospital on the same day to perform the admission H&P (9922x-57, AI). The abscess requires I&D the next day (21501). 5

6 Office Endoscopy Nasal Endoscopy Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure) Evaluation of the nasal passages Tip: The parenthetical statement (separate procedure) means this procedure may be billed when it is a completely separate procedure from others performed at the same operative session. Do not report a separate procedure when included in a more extensive CPT code (e.g., is included in all surgical endoscopic sinus surgery codes such as 31255). Diagnostic Sinus Endoscopy Nasal/sinus endoscopy, diagnostic with maxillary sinusoscopy (via inferior meatus or canine fossa puncture) Nasal/sinus endoscopy, diagnostic with sphenoid sinusoscopy (via puncture of sphenoidal face or cannulation of ostium) CPT and require a puncture or trocar cannulation prior to placing the scope into the sinus. Do not report or for diagnostic sinus endoscopy performed via an existing and patent opening into the maxillary or sphenoid sinus is incorrect. These procedures are typically performed in the operating room. Nasopharyngoscopy Nasopharyngoscopy with endoscope (separate procedure) Evaluation of the nose, nasopharynx and pharynx Flexible Fiberoptic Laryngoscopy (FFL) Laryngoscopy, flexible fiberoptic; diagnostic Evaluation of the nose, nasopharynx, pharynx and larynx Do not also report for nasal endoscopy performed at the same time 6

7 Office Endoscopy Transnasal Esophagoscopy Esophagoscopy, rigid or flexible; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) Requires evaluation of the esophagus down to the gastro-esophageal (GE) junction. Append modifier 52 (reduced services) if evaluation down to the gastroesophageal junction is not performed Tracheobronchoscopy Tracheobronchoscopy through established tracheostomy incision Use for full bronchoscopy via tracheostomy. Append modifier 52 (reduced services) if only tracheoscopy, without full bronchoscopy, was performed. See code series (direct laryngoscopy) for tracheoscopy (without full bronchial exam) when not performed via tracheostomy. FAQ Q: Can I bill for a mirror exam using the indirect laryngoscopy code (31505)? I do one on almost all my new patient visits. A: No, this is part of an ENT exam and not separately reported. 7

8 Office Endoscopy Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement (separate procedure) Example: Patient returns two days after endoscopic sinus surgery and septoplasty. The physician performs bilateral endoscopic sinus debridement. ICD-9-CM Code(s): Chronic Ethmoid Sinusitis Chronic Maxillary Sinusitis CPT Code/ Modifier(s) Description ICD-9-CM Code 8-NF Reported Expected RVU- NF Paid , 79 Endoscopy, unilateral Endoscopy, unilateral 1, 2 1, OR , 79 Endoscopy, bilateral 1, Debridement: The removal of foreign material, and devitalized, or infected tissue from or adjacent to a traumatic or infected lesion until surrounding healthy tissue is seen. Use CPT to report post-operative endoscopic debridements performed outside the 0-day global surgery period following FESS. Do not use CPT for non-endoscopic nasal sinus debridements. CPT Assistant, December 2011 Although two to three debridements in the first 30 days is typical for the majority of patients, once a week may be an appropriate frequency for postoperative debridement in select patients with difficult problems. However, the frequency and length of time for which debridement is medically necessary will vary from case to case and must be individualized, a conclusion, which multiple studies analyzing debridement outcomes have acknowledged. While their limited use will likely suffice in the majority of cases, there are situations in which a patient may require more frequent, very long-term debridements. Clinically, these include but are not limited to: o Persistent crusting within the surgical bed, o Adhesion formation noted upon examination, o More extensive surgery (e.g., complex frontal sinusotomies, neoplasm resections), o Underlying immunologic disorders, o Diffuse polyposis, o Revision FESS, mucociliary disorders, o Allergic fungal sinusitis, o And postoperative complications (e.g., visual loss, cerebrospinal fluid leak). Tip: Do not report an E&M code with unless there is also a significant, separately identifiable service provided (e.g., a different diagnosis such as acute otitis media). 8

9 Tonsillectomy/Adenoidectomy Tonsillectomy Alone < age age 12 Adenoidectomy With Adenoidectomy < age age 12 Primary (first one) < age age 12 Secondary (subsequent) < age age 12 Tips: All codes have a 90-day global period, per CMS Biopsy(ies) obtained of the nasopharyngeal tissue in conjunction with a T&A is not separately reported. May separately bill for the biopsy if only a tonsillectomy is performed. CMS says: Do not bill for treatment of complications in the global period unless there is a return to the OR (then append billed CPT code with modifier 78). Unplanned overnight stay on the day of procedure is not separately reported if reason is due to surgery (e.g., pain, dehydration). Unplanned re-admissions (e.g., dehydration) may be separately reported with modifier 24. What about post-op tonsillectomy bleeds? o In-office treatment Medicare says do not bill; check with other payors for policy o In ER Medicare says do not bill; check with other payors for policy o Return to the OR bill with modifier Control oropharyngeal hemorrhage, primary or secondary (e.g., post-tonsillectomy); simple complicated, requiring hospitalization with secondary surgical intervention (e.g., suture ligation of bleeders) Primary = within 24 hrs after surgery, secondary = 24 hours to two weeks later and involve clot evacuation, applying pressure with sponges, electrocautery, application of vasoconstrictor solutions such as tannic acid, silver nitrate and epinephrine involves surgical intervention (e.g., suture ligation of bleeding vessels) Refer to CPT for postop adenoidectomy bleed control in the OR and append modifier 78. 9

10 Turbinate Procedures CPT Code Description Ablation, soft tissue of inferior turbinates, unilateral or bilateral, any method (e.g., electrocautery, radiofrequency ablation, or tissue volume reduction); superficial Unilateral/ Bilateral Unilateral or Bilateral (no modifier 50) intramural (i.e., submucosal) Unilateral or Bilateral (no modifier 50) Fracture nasal inferior turbinate(s), therapeutic Excision inferior turbinate, partial or complete, any method Submucous resection inferior turbinate, partial or complete, any method Coding Tips: Do not report in conjunction with Unilateral or Bilateral (no modifier 50) Unilateral (modifier 50 acceptable) Unilateral (modifier 50 acceptable) For 30140: The documentation should indicate the mucosa was entered/incised and preserved and tissue and/or bone was removed. A statement such as excised the turbinate(s) is not sufficient to accurately take into account the submucous resection of the inferior turbinate(s), and would not support Do not report for turbinate reduction refer to or Do not report 30801, 30802, and in conjunction with or Performing middle turbinate surgery to gain access to the sinuses is not separately reported. It may be necessary to apend modifier 59 to when reported with to show separate procedures were performed. 10

11 Endoscopic Sinus Surgery CPT Description Code Nasal/sinus endoscopy, surgical; with concha bullosa resection Nasal/sinus endoscopy, surgical; with ethmoidectomy, partial (anterior) with ethmoidectomy, total (anterior and posterior) Nasal/sinus endoscopy, surgical with maxillary antrostomy; with removal of tissue from maxillary sinus Nasal/sinus endoscopy, surgical with frontal sinus exploration, with or without removal of tissue from frontal sinus Nasal/sinus endoscopy, surgical with sphenoidotomy; with removal of tissue from the sphenoid sinus Remember: May separately report for endoscopic resection of concha bullosa when appropriately documented (e.g., pre-op diagnosis, CT scan findings). Otherwise, middle turbinate surgery is included in the endoscopic sinus surgery codes. Removal of tissue for and = polyps, mucocele, fungus ball; not debris, contents, mucous or pus. Do not report with the balloon dilation codes ( ) for procedures on the same sinus. Report the above codes when tissue and/or bone is removed. All of the above codes include removal of nasal polyps from the same side at the same operative session; do not separately report (or 30110, 30115). Stereotactic Computer Assisted Navigation (SCAN) CPT Description Code Nasal/sinus endoscopy, surgical; with dilation of maxillary sinus ostium (eg, balloon dilation), transnasal or via canine fossa with dilation of frontal sinus ostium (eg, balloon dilation) with dilation of sphenoid sinus ostium (eg, balloon dilation) Coding Tips: Report above code when tissue is displaced. If tissue and/or bone is removed, then see codes If tissue is both displaced and removed, then see codes There is no current balloon technology for use in the ethmoid sinus; therefore, there is no ethmoid code. Beware: Some payors consider this experimental or investigational and will not pay. This service may possibly be billed to the patient. Codes include fluoroscopy do not separately report Do not report in conjunction with 31233, 31256, or when performed on the same sinus. Do not report in conjunction with when performed on the same sinus. Do not report in conjunction with 31235, 31287, or when performed on the same sinus. Non-facility RVUs are high due to the practice expense incurred associated with purchasing the equipment. Although, the NF RVUs did decrease by almost half in 2012 (compared to 2011). Do not separately report a lavage code (31000, 31002) with the above codes. 11

12 Stereotactic Computer Assisted Navigation (SCAN) Stereotactic computer assisted volumetric (navigational) procedure, cranial, extradural (List separately in addition to code for primary procedure) AAO-HNS Policy on Intra-Operative Use of Computer Aided Surgery The American Academy of Otolaryngology Head and Neck Surgery endorses the intraoperative use of computer-aided surgery in appropriately select cases to assist the surgeon in clarifying complex anatomy during sinus and skull base surgery. There is sufficient expert consensus opinion and literature evidence base to support this position. This technology is used at the discretion of the operating surgeon and is not experimental or investigational. These appropriate, specialty specific, and surgically indicated procedural services should be reimbursed whether used by neurosurgeons or other qualified physicians regardless of the specialty. Examples of indications in which use of computer-aided surgery may be deemed appropriate include: 1) Revision sinus surgery. 2) Distorted sinus anatomy of development, postoperative, or traumatic origin. 3) Extensive sino-nasal polyposis. 4) Pathology involving the frontal, posterior ethmoid and sphenoid sinuses. 5) Disease abutting the skull base, orbit, optic nerve and carotid artery. 6) CSF rhinorrhea or conditions where there is a skull base defect. 7) Benign and malignant sino-nasal neoplasms. Documentation Requirements per American Rhinologic Society Include in the Indications for Surgery paragraph the medical necessity of need for stereotactic guidance. Document pre-op surgical planning including downloading and verifying images. Document registration of data. Document instrument calibration. Document Target Registration Error (TRE). Document anatomic localization and confirmation during surgery. Include endoscopic approach and intra-operative computer findings. Tip: Be sure to document the need for use of navigational assistance this provides the medical necessity for the additional charge. 12

13 Endoscopic Sinus Surgery Cases 1. Procedure: Bilateral endoscopic maxillary antrostomies with tissue removal Detail: endoscope was used..the middle turbinate was medialized.the uncinate was noted to be without any polypoid changes a right-angle curette was utilized to forward-fracture the uncinate and the microdebrider was utilized to take down the uncinate this revealed evidence of polypoid changes at the maxillary sinus ostium causing occlusion of the ostium on the left.microdebrider was utilized to remove the polypoid changes and a micropunch was utilized to widen the maxillary sinus ostium on the left..same procedure performed on right side. Choose the correct code combination: A B Bilateral endoscopic total ethmoidectomies Bilateral endoscopic sphenoidotomies Bilateral endoscopic maxillary antrostomies with removal of polyps from within the maxillary sinuses Use of stereotactic navigation and image-guided system Choose the correct code combination: A B

14 Endoscopic Sinus Surgery Cases 3. Septoplasty, bilateral inferior turbinate submucous resections, bilateral endoscopic nasal polypectomies, bilateral endoscopic maxillary antrostomies and bilateral endoscopic anterior ethmoidectomies. Choose the correct code combination: A B , Operative note reads: Balloon sinus ostia catheterization and dilation of both maxillary sinuses under fluoroscopy. There is no documentation of removal of bone and mucosa. Choose the correct code combination: A B

15 Endoscopic Sinus Surgery Cases 5. Operative note reads: Bilateral endoscopic maxillary antrostomies using forceps and microdebrider for removal of bone and mucosa as well as balloon catheter sinus ostia dilation technology under fluoroscopy. Choose the correct code combination: A B Bilateral endoscopic total ethmoidectomies, bilateral endoscopic maxillary antrostomies, bilateral outfracture and submucous resection of inferior turbinates, septoplasty Choose the correct code combination: A , 59 B Septoplasty, endoscopic sphenoidotomy, and approach for neurosurgeon to remove a pituitary tumor. Choose the correct code combination: A B

16 Snoring/Sleep Apnea Procedures In addition to the septoplasty, tonsillectomy and turbinate codes, the most common CPT codes used for insurance billed procedures include: CPT Code Description Global Period Osteotomy, mandible, segmental; with genioglossus 90 advancement Hyoid myotomy and suspension Tongue base suspension, permanent suture technique Submucosal ablation of the tongue base, radiofrequency, 10 one or more sites, per session Palatopharyngoplasty (e.g., uvulopalatopharyngoplasty, 90 uvulopharyngoplasty) Note: Many payors do not reimburse for or Obtain written prior authorization. RVU-NF for are high because the physician assumes the practice expense for performing the procedure (e.g., radiofrequency probe). Don t forget to use separate diagnoses for these procedures such as turbinate hypertrophy, tonsillar hypertrophy, deviated septum, etc. Remember: Use an unlisted code (42299) for a LAUP (laser-assisted uvulopalatoplasty). Example Procedures performed: Septoplasty, Bilateral submucosal inferior turbinate reduction using radiofrequency, Coblation of the tongue base, Tonsillectomy, Uvulopalatopharyngoplasty Choose the correct code combination: A , , 50 B

17 Ear Procedures TYMPANOSTOMY TUBE PLACEMENT Local or topical Type of Anesthesia General Codes may be reported bilaterally with modifier 50. CMS says: 10-day global period. Do not separately bill myringotomy it s included in 69433/ Tube placement is included in a larger primary procedure performed on the same ear (e.g., tympanoplasty). Includes use of the microscope; do not separately report or Remember to use correct billing format as required by payor: o on one line versus and on two lines TYMPANOSTOMY TUBE REMOVAL Ventilating tube removal requiring general anesthesia Code has a 0-day postoperative global period May be reported with modifier 50 if performed bilaterally Tube removed without general anesthesia may be reported with an E&M code, (binocular microscopy), or other appropriate code. It is not a foreign body removal ( ). Tube removal with another procedure on the same ear (e.g., perforation repair, tympanoplasty, mastoidectomy) is included in the larger primary procedure and not separately reported. Scenario: The surgeon who originally placed the tympanostomy (ventilating) tubes brings the patient to the outpatient facility. Under general anesthesia and utilizing an operating microscope, the surgeon creates a relaxing incision. The surgeon removes the tube with surrounding granulation tissue, thus creating an optimal situation for closure of the perforation in which the tube was situated. Monitoring of the ear in the office setting revealed the perforation to have closed within several weeks time. Scenario: Removal of a tympanostomy tube from the external auditory canal. Is this a foreign body removal? No, it is not a foreign body removal. This is part of your E&M code when performed in your office; you may report if you use the microscope. If performed in the operating room, consider using (Otolaryngologic examination under general anesthesia). Append modifier 52 (reduced services) if a full ENT exam under anesthesia is not performed. 17

18 Ear Procedures FOREIGN BODY REMOVAL Removal foreign body from external auditory canal; without general anesthesia with general anesthesia Use for removal of items such as beads, insects, ear candling wax, etc.; do not use for removal of a tympanostomy tube. Includes use of the microscope; do not separately report or TYMPANIC MEMBRANE REPAIR CPT Code Description Comments Tympanic membrane May be reported with modifier 50 repair, with or without CMS says: 10-day global period site preparation of Example: Freshening the edges of the perforation for perforated area of the tympanic closure, with or membrane, paper patch graft without patch Myringoplasty (surgery confined to drumhead and donor area) May be reported with modifier 50 CMS says: 90-day global period A fat graft plug or a temporalis fascia graft may be placed medially to the eardrum Includes the harvesting of a donor graft when performed (do not separately report code such as 20926). The middle ear is not entered in this procedure 18

19 Ear Procedures TYMPANOPLASTY (Initial or Revision) CPT Description Code Tympanoplasty without mastoidectomy (including canaloplasty, atticotomy and/or middle ear surgery), initial or revision; without ossicular chain reconstruction with ossicular chain reconstruction (e.g., post fenestration) with ossicular chain reconstruction and synthetic prosthesis (e.g., partial ossicular replacement prosthesis [PORP], total ossicular replacement prosthesis [TORP]) Tips from CPT Assistant, August 2008: May be done transcanal or via a postauricular incision Graft harvest through a separate skin incision for repair/reconstruction may be reported separately (e.g., 20926). Codes require entry and inspection of the middle ear. Middle ear exploration (69440), exploratory tympanotomy, tube placement (69436), or membrane repair (69610) are not separately reportable. Scenario: I m working on an appeal for a denial we received in Can you please help? We billed (transcanal tympanoplasty) and for harvesting a temporalis fascia graft. We also billed 69990, x 2 units (for 2 hours of intraoperative monitoring) and (somatosensory evoked potential study of the head and neck). We got paid on and but denied on the rest of the codes. Please help! Action: The intraoperative monitoring codes, and 95927, should not have been billed. Write off these charges. Intraoperative nerve monitoring was not separately billable for the surgeon in 2012 nor is it billable for the surgeon in CPT may or may not be reimbursed depending on payer policy; Medicare will not reimburse when billed with the auditory system codes. 19

20 Neck Dissection Neck Dissection CPT Codes Suprahyoid lymphadenectomy Cervical lymphadenectomy (complete) Cervical lymphadenectomy (modified radical neck dissection) Coding Tips = suprahyoid; involves removal of level I nodes only (CPT Assistant, August 2010) = modified radical or selective neck dissection (removal of lymph nodes in levels I - V; involves the removal of all lymph nodes routinely removed by radical neck dissection, while preserving the internal jugular vein, the spinal accessory nerve and/or the sternocleidomastoid muscle. Involves removal of more than level I nodes = complete or radical; includes all five regions of the neck. In addition, the internal jugular vein, the spinal accessory nerve, and the sternocleidomastoid muscle are removed. It is appropriate to report a neck dissection code (e.g., 38724) with a direct laryngoscopy (e.g., 31525) if both are performed. The laryngoscopy is a separate diagnostic service and is not included in the neck dissection codes. Be sure to document lymph node removal. If the procedure is performed after radiation therapy has been delivered then be sure to document tissue removal. ALERT: There is no CPT code for only a neck dissection! Do not use a primary procedure code if it includes a radical neck dissection and you ve done a modified radical neck dissection. Rather, report the primary code that does not include a neck dissection and separately report the modified radical neck dissection code(s). o Example: Laryngectomy with bilateral modified radical neck dissections Do Don t Laryngectomy w/o RND Laryngectomy w/rnd MRND MRND , 59 MRND 20

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