2017 EAR, NOSE & THROAT (ENT) SURGERY MEDICARE REIMBURSEMENT CODING GUIDEEffective January 1, 2017
PHYSICIAN3 HOSPITAL OUTPATIENT4 ASC4
CPT CODE1/HCPCSCODE2
CODE DESCRIPTION
MEDICARE NAT’L AVGCF=$35.887 APC AND APC
DESCRIPTIONMEDICARE NAT’L AVG
MEDICARE NAT’L AVGFACILITY
SETTINGNON-FACILITY
SETTING
CERVICAL RESECTION (MODIFIED RADICAL NECK DISSECTION)
38720 Cervical lymphadenectomy (complete) $1,389 NA
5093, Level 3 Breast/Lymphatic Surgery and Related Procedures
$6,486 N/A for ASC
38724 Cervical lymphadenectomy (modified radical neck dissection) $1,501 NA Inpatient only, not reimbursed for hospital
outpatient or ASC
PARATHYROID PROCEDURES
60500 Parathyroidectomy or exploration of parathyroid(s) $999 NA 5165, Level 5 ENT Procedures $4,131 $2,040
60502 Parathyroidectomy or exploration of parathyroid(s); re-exploration $1,333 NA 5165, Level 5 ENT
Procedures $4,131 N/A for ASC
60505Parathyroidectomy or exploration of parathyroid(s); with mediastinal exploration, sternal split or transthoracic approach
$1,433 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 $643 NA 5165, Level 5 ENT
Procedures $4,131 $2,040
42415Excision of parotid tumor or parotid gland; lateral lobe, with dissection and preservation of facial nerve
$1,093 NA 5165, Level 5 ENT Procedures $4,131 $2,040
42420 Excision of parotid tumor or parotid gland; total, with dissection and preservation of facial nerve $1,226 NA 5165, Level 5 ENT
Procedures $4,131 $2,040
42425 Excision of parotid tumor or parotid gland; total, en bloc removal with sacrifice of facial nerve $865 NA 5165, Level 5 ENT
Procedures $4,131 $2,040
42426 Excision of parotid tumor or parotid gland; total, with unilateral radical neck dissection $1,398 NA Inpatient only, not reimbursed for hospital
outpatient or ASC
42440 Excision of submandibular (submaxillary) gland $426 NA 5165, Level 5 ENT Procedures $4,131 $2,040
42450 Excision of sublingual gland $372 $468 5165, Level 5 ENT Procedures $4,131 $2,040
42500 Plastic repair of salivary duct, sialodochoplasty; primary or simple $355 $448 5165, Level 5 ENT
Procedures $4,131 $2,040
42505 Plastic repair of salivary duct, sialodochoplasty; secondary or complicated $469 $573 5165, Level 5 ENT
Procedures $4,131 $2,040
Medicare National Average Rates and Allowables(Not Adjusted for Geography)
PHYSICIAN3 HOSPITAL OUTPATIENT4 ASC4
CPT CODE1/HCPCSCODE2
CODE DESCRIPTION
MEDICARE NAT’L AVGCF=$35.887 APC AND APC
DESCRIPTIONMEDICARE NAT’L AVG
MEDICARE NAT’L AVGFACILITY
SETTINGNON-FACILITY
SETTING
PAROTID PROCEDURES CONT’D
42507 Parotid duct diversion, bilateral (Wilke type procedure) $520 NA 5165, Level 5 ENT
Procedures $4,131 $2,040
42509Parotid duct diversion, bilateral (Wilke type procedure); with excision of both submandibular glands
$874 NA 5165, Level 5 ENT Procedures $4,131 $2,040
42510Parotid duct diversion, bilateral (Wilke type procedure); with ligation of both submandibular (Wharton's) ducts
$669 NA 5164, Level 4 ENT Procedures $2,174 $941
THYROID PROCEDURES
60212Partial thyroid lobectomy, unilateral; with contralateral subtotal lobectomy, including isthmusectomy
$1,043 NA 5361, Level 1 Laparoscopy $4,199 $2,040
60225Total thyroid lobectomy, unilateral; with contralateral subtotal lobectomy, including isthmusectomy
$962 NA 5361, Level 1 Laparoscopy $4,199 $2,040
60240 Thyroidectomy, total or complete $950 NA 5361, Level 1 Laparoscopy $4,199 $2,040
60252 Thyroidectomy, total or subtotal for malignancy; with limited neck dissection $1,367 NA 5165, Level 5 ENT
Procedures $4,131 N/A for ASC
60254 Thyroidectomy, total or subtotal for malignancy; with radical neck dissection $1,724 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
$1,130 NA 5165, Level 5 ENT Procedures $4,131 N/A for
ASC
60270 Thyroidectomy, including substernal thyroid; sternal split or transthoracic approach $1,418 NA Inpatient only, not reimbursed for hospital
outpatient or ASC
60271 Thyroidectomy, including substernal thyroid; cervical approach $1,094 NA 5165, Level 5 ENT
Procedures $4,131 N/A for ASC
TONSIL AND ADENOID PROCEDURES
42800 Biopsy; oropharynx $116 $163 5164, Level 4 ENT Procedures $2,174 $104
42804 Biopsy; nasopharynx, visible lesion, simple $117 $201 5164, Level 4 ENT Procedures $2,174 $941
42806 Biopsy; nasopharynx, survey for unknown primary lesion $136 $226 5164, Level 4 ENT
Procedures $2,174 $941
42809 Removal of foreign body from pharynx $127 $207 5735, Level 5 Minor Procedures $264 Pkg’d Pmt
42810 Excision branchial cleft cyst or vestige, confined to skin and subcutaneous tissues $299 $399 5164, Level 4 ENT
Procedures $2,174 $941
42815Excision branchial cleft cyst, vestige, or fistula, extending beneath subcutaneous tissues and/or into pharynx
$579 NA 5165, Level 5 ENT Procedures $4,131 $2,040
42820 Tonsillectomy and adenoidectomy; under age 12 $299 NA 5165, Level 5 ENT Procedures $4,131 $2,040
42821 Tonsillectomy and adenoidectomy; age 12 and over $312 NA 5164, Level 4 ENT Procedures $2,174 $941
42825 Tonsillectomy, primary or secondary; under age 12 $271 NA 5165, Level 5 ENT Procedures $4,131 $2,040
42826 Tonsillectomy, primary or secondary; age 12 and over $260 NA 5164, Level 4 ENT
Procedures $2,174 $941
42830 Adenoidectomy, primary; under age 12 $214 NA 5164, Level 4 ENT Procedures $2,174 $941
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. http://www.cms.gov/Medicare/Coding/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 2016 Final Rule; 81 Fed. Reg. 80170-80562 : https://www.gpo.gov/fdsys/pkg/FR-2016-11-15/pdf/2016-26668.pdf. Published November 15, 2016. See also the January 2017 release of the PFS Relative Value File RVU16A at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/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. 24; 24-37 [ CMS- 1656-CN]: https://www.federalregister.gov/documents/2017/01/03/2016-31774/medicare-program-hospital-outpatient-prospective-payment-and-ambulatory-surgical-center-payment. Published January 3, 2017. Payment is adjusted by the wage index for each hospital or ASC’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.
PHYSICIAN3 HOSPITAL OUTPATIENT4 ASC4
CPT CODE1/HCPCSCODE2
CODE DESCRIPTION
MEDICARE NAT’L AVGCF=$35.887 APC AND APC
DESCRIPTIONMEDICARE NAT’L AVG
MEDICARE NAT’L AVGFACILITY
SETTINGNON-FACILITY
SETTING
TONSIL AND ADENOID PROCEDURES CONT’D
42831 Adenoidectomy, primary; age 12 and over $231 NA 5164, Level 4 ENT Procedures $2,174 $941
42835 Adenoidectomy, secondary; under age 12 $188 NA 5164, Level 4 ENT Procedures $2,174 $941
42836 Adenoidectomy, secondary; age 12 and over $249 NA 5164, Level 4 ENT Procedures $2,174 $941
42842 Radical resection of tonsil, tonsillar pillars, and/or retromolar trigone; without closure $1,057 NA 5165, Level 5 ENT
Procedures $4,131 N/A for ASC
42844Radical resection of tonsil, tonsillar pillars, and/or retromolar trigone; closure with local flap (eg, tongue, buccal)
$1,455 NA 5165, Level 5 ENT Procedures $4,131 N/A for
ASC
42860 Excision of tonsil tags $195 NA 5164, Level 4 ENT Procedures $2,174 $941
42870 Excision or destruction lingual tonsil, any method (separate procedure) $621 NA 5165, Level 5 ENT
Procedures $4,131 $2,040
42890 Limited pharyngectomy $1,499 NA 5165, Level 5 ENT Procedures $4,131 $2,040
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
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 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 2016, p.38-40. 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. 2016 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 FY2017—effective January 1, 2017
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 2017 RELATIVE
WEIGHT1
FY 2017 GEOMETRIC MEAN LENGTH OF STAY1
FY 2017 SUBJECT TO PACT?1,3
FY 2017 MEDICARE NATIONAL AVERAGE4
CERVICAL RESECTION (MODIFIED RADICAL NECK DISSECTION)
129Major Head and Neck Procedures W CC/MCC or Major Device
2.3305 3.9 No $13,898
130 Major Head and Neck Procedures W/O CC/MCC 1.4598 2.3 No $8,705
PARATHYROID PROCEDURES
625Thyroid, Parathyroid and Thyroglossal Procedures W MCC
2.6769 5.1 No $15,964
626Thyroid, Parathyroid and Thyroglossal Procedures W CC
1.5039 2.4 No $8,968
627Thyroid, Parathyroid and Thyroglossal Procedures W/O CC/MCC
1.0183 1.5 No $6,073
PAROTID PROCEDURES
139 Salivary Gland Procedures 1.0271 1.7 No $6,125
THYROID PROCEDURES5
625Thyroid, Parathyroid and Thyroglossal Procedures W MCC
2.6769 5.1 No $15,964
626Thyroid, Parathyroid and Thyroglossal Procedures W CC
1.5039 2.4 No $8,968
627Thyroid, Parathyroid and Thyroglossal Procedures W/O CC/MCC
1.0183 1.5 No $6,073
TONSIL AND ADENOID PROCEDURES6
133Other Ear, Nose, Mouth and Throat OR Procedures W CC/MCC
1.9147 3.9 No $11,418
134Other Ear, Nose, Mouth and Throat OR Procedures W/O CC/MCC
1.0515 2.0 No $6,271
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.
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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 FY2017 Rates Final Rule, 81 Fed. Reg. 80170-80562: https://www.gpo.gov/fdsys/pkg/FR-2016-11-15/pdf/2016-26668.pdf. Published November 15, 2016.
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 ($5,516.14) plus the capital standard amount ($446.79). 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 FY2017 Rates; Correction, 81 Fed. Reg. 68947-68963. Tables 1A-1E. https://www.gpo.gov/fdsys/pkg/FR-2016-10-05/pdf/2016-24042.pdf. Published October 5, 2016. 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 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.