Nasopharyngoscopy With Dilation of Eustachian Tube

 CPT Assistant, April 2021, Volume 31, Issue 4, page 12

For the Current Procedural Terminology (CPT®) code set, two new Category I codes (69705, 69706) were added to the Middle Ear subsection of the Auditory System section. This article provides an overview of these new codes.

Middle Ear

Other Procedures

 

 

69705 

Nasopharyngoscopy, surgical, with dilation of eustachian tube (ie, balloon dilation); unilateral 

 

 

69706 

bilateral 

 

 

 

(Do not report 69705, 69706 in conjunction with 31231, 92511)

Prior to 2021, there was no specific CPT code to report surgical nasopharyngoscopy with dilation of the eustachian tube (ie, balloon dilation). This procedure was previously reported with code 69799, Unlisted procedure, middle ear.

The new procedure is clinically referred to as eustachian tube balloon dilation (ETBD), which may be performed for the treatment of disorders related to middle ear aeration or ventilation (eg, obstructive eustachian tube dysfunction [OETD]) contributing to middle ear effusion and related disorders (eg, retraction pockets, cholesteatoma, atelectatic otitis media).

Although inflation of the eustachian tube is included in codes 69420, Myringotomy including aspiration and/or eustachian tube inflation, and 69421, Myringotomy including aspiration and/or eustachian tube inflation requiring general anesthesia, these inflation procedures are performed through an incision in the eardrum and do not describe nasopharyngoscopic ETBD. An exclusionary parenthetical note was added after code 69706 to indicate that codes 69705 and 69706 should not be reported with code 31231, Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure), or 92511, Nasopharyngoscopy with endoscope (separate procedure).

The following clinical examples and procedural descriptions reflect typical clinical situations for which codes 69705 and 69706 would be appropriately reported.

Clinical Example (69705)

A 45-year-old female with adult life-long history of difficulty equalizing her left ear with altitude changes develops a left middle ear effusion after a flight. Despite medical management over 3 months, her left middle ear effusion persists with a type B tympanogram and conductive hearing loss. She is scheduled for surgical nasopharyngoscopy with left eustachian tube dilation.

Description of Procedure (69705)

Remove previously placed pledgets. Under endoscopic visualization, place pledgets soaked in decongestant and anesthetic in the nasopharynx followed by a wait-time for them to take effect. Remove pledgets and inject an intranasal anesthetic/vasoconstrictive agent into the middle turbinate followed by a wait-time for this to take effect. Holding the guide catheter by the proximal hub and under endoscopic visualization, insert it through the nose on the side to be treated and near the orifice of the eustachian tube. Then rotate and stabilize the guide catheter so that the tip angle is aligned with the trajectory of the eustachian tube. Advance the balloon catheter through the guide into the eustachian tube. Inflate the balloon to the desired pressure while monitoring the diameter, shape, and position of the balloon under endoscopic visualization and monitoring for any signs of bleeding from the internal carotid artery. Perform additional inflation followed by balloon deflation, retract into the guide catheter, and remove along with the entire system.

Clinical Example (69706)

A 56-year-old male with adult life-long history of difficulty equalizing his ears with flights develops an upper respiratory infection and subsequent middle ear effusion bilaterally. Despite medical management over three months, his middle ear effusions persist with type B tympanograms and conductive hearing loss. He is scheduled for surgical nasopharyngoscopy with bilateral eustachian tube dilation.

Description of Procedure (69706)

Remove previously placed pledgets. Under endoscopic visualization, place pledgets soaked in decongestant and anesthetic in the nasopharynx followed by a wait-time for them to take effect. Remove pledgets and inject an intranasal anesthetic/vasoconstrictive agent into the middle turbinate followed by a wait-time for this to take effect. Holding the guide catheter by the proximal hub and under endoscopic visualization, insert it through the nose on the side to be treated and near the orifice of the eustachian tube. Then rotate and stabilize the guide catheter so that the tip angle is aligned with the trajectory of the eustachian tube. Advance the balloon catheter through the guide into the eustachian tube. Inflate the balloon to the desired pressure while monitoring the diameter, shape, and position of the balloon under endoscopic visualization and monitoring for any signs of bleeding from the internal carotid artery. Perform additional inflation followed by balloon deflation, retract into the guide catheter, and remove along with the entire system. Repeat the entire procedure on the contralateral side.

Surgery: Musculoskeletal System, Peroneus Brevis Tendon Transfer, 27690 (Q&A)

 CPT Assistant, May 2021, Volume 31, Issue 5, page 13

Question:

Should code 27690 or 27691 be reported if a physician performed a transfer of the peroneus brevis tendon to the peroneus longus tendon?

Answer:

Peroneal tendon transfers to the same side of the foot should be reported as a superficial tendon transfer; therefore, report code 27690, Transfer or transplant of single tendon (with muscle redirection or rerouting); superficial (eg, anterior tibial extensors into midfoot). 

Surgery: Musculoskeletal System, Proximal Interphalangeal (PIP) Joint Release, 26123 (Q&A)

 CPT Assistant, May 2021, Volume 31, Issue 5, page 13

Question:

What specifically constitutes a release of the proximal interphalangeal (PIP) joint as described in code 26123? Is excision of the cord sufficient to report a release or does it require capsulotomy, capsulectomy, and/or volar plate release?

Answer:

Excision of the cord to release the PIP joint is sufficient to report code 26123, Fasciectomy, partial palmar with release of single digit including proximal interphalangeal joint, with or without Z-plasty, other local tissue rearrangement, or skin grafting (includes obtaining graft). Skin lengthening through Z-plasty or skin graft, excision of the diseased fascial cord, and any necessary capsuloligamentous releases, when performed, are inherent to code 26123 and may not be reported separately.

Surgery: Integumentary System, Mastotomy with Biopsy, 19020, 19101 (Q&A)

 CPT Assistant, May 2021, Volume 31, Issue 5, page 13

Question:

While performing a mastotomy on a patient for a breast abscess, the surgeon noticed abnormal tissue and performed a biopsy of the tissue for pathology review. May both procedures be reported?

Answer:

Yes, a biopsy of a mass or lesion is not inherent to a mastotomy for a breast abscess. Both codes 19020, Mastotomy with exploration or drainage of abscess, deep, and 19101, Biopsy of breast; open, incisional, may be reported.

Coding Brief: Breast Localization Clips Placement and Mastectomy Procedures

 CPT Assistant, May 2021, Volume 31, Issue 5, page 11

For the Current Procedural Terminology (CPT®) 2018 code set, a new parenthetical note was added to the Breast subsection of the Integumentary System section that states: "[i]ntraoperative placement of clip[s] is not separately reported." Since publication of these changes, there have been questions about when to correctly report percutaneous placement of breast localization device(s) (19281-19288), such as a clip, when performed the same day but prior to a mastectomy procedure (19301-19307). This coding brief will clarify appropriate reporting of these separate services when performed on the same day.

Coding Tip

"Intraoperative" refers to the "skin-to-skin" work of an operative procedure. It does not include pre- or post-service work, which may include separately reportable procedures or services.

For the CPT 2020 code set, new guidelines were added in the introduction of the Breast subsection to instruct reporting the appropriate percutaneous image-guided localization device placement code(s) (19281-19288) when performed prior to an open breast biopsy or open excision of a breast lesion. This includes percutaneous placement of a breast localization device prior to the intraoperative (ie, skin-to-skin) component of an open mastectomy procedure.

During image-guided percutaneous clip placement, typically performed by a radiologist or surgeon, views are obtained which will be used for pre-surgical planning. For example, part of the preservice work for a partial mastectomy (19302) is to review the localization mammogram with the radiologist, who performed the needle-localization procedure, so that the surgeon can plan the optimal location of the skin incisions and operative approach to the area of concern.

A typical scenario is one that would involve a patient who undergoes image-guided percutaneous placement of a localization device (eg, clip or wire) in the radiology department, and later undergoes an open partial mastectomy in the operating room. If, for example, mammographic imaging were used to percutaneously place the device, the radiologist would report code 19281, Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including mammographic guidance. The radiologist does not append a modifier to code 19281 if no other services were performed.

A less common scenario involves the surgeon performing the image-guided percutaneous placement of a localization device prior to starting an open mastectomy procedure, either in another suite, in the preoperative holding area, or in the operating room. If, for example, ultrasound imaging were used to percutaneously place the device, the surgeon would report code 19285, Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including ultrasound guidance, with modifier 59, Distinct Procedural Service, appended to indicate that the procedure was distinct from the mastectomy procedure. Note that Healthcare Common Procedure Coding System (HCPCS) modifier XE, Separate Encounter, may also be appropriately reported depending on the policy of third-party payers.

In summary, the intent of the parenthetical note of "(Intraoperative placement of clip[s] is not separately reported)" following the mastectomy codes was to disallow and prevent separate reporting of placing a device in the open mastectomy wound or cavity, for example, to mark the margins of the excision for future operations or services (eg, radiation therapy). This was to acknowledge the minimal work required to place a clip or wire in an open wound. The qualifying factor for reporting image-guided percutaneous localization device placement is that the device is not placed intraoperatively (ie, during the skin-to-skin portion of a mastectomy procedure), which would not be separately reportable.

Surgery: Digestive System, 42820, 42821, 42825, 42826 (Q&A)

 CPT Assistant, June 2021, Volume 31, Issue 6, page 14

Question:

What is the correct coding for an intracapsular tonsillectomy with adenoidectomy? Is it appropriate to indicate reduced services by appending a modifier to the code because a thin layer of tonsil was left in place?

Answer:

It would be appropriate to report the age-appropriate tonsillectomy with adenoidectomy code 42820, Tonsillectomy and adenoidectomy; younger than age 12, or 42821, Tonsillectomy and adenoidectomy; age 12 or over, without appending modifier 52, Reduced Services. Similarly, if only an intracapsular tonsillectomy was performed, it would be reported with the unmodified and age-appropriate code 42825, Tonsillectomy, primary or secondary; younger than age 12, or 42826, Tonsillectomy, primary or secondary; age 12 or over. This is because the work involved and the surgical outcome achieved are essentially the same as a classic tonsillectomy. To clarify, "intracapsular" refers only to the tonsillectomy; there is no capsule associated with the adenoids. There is no coding difference for tonsillectomies performed with different modalities (eg, scalpel, electrocautery, laser, radiofrequency ablation) because the work and outcomes are similar.

Surgery: Urinary System, 52601 (Q&A)

 CPT Assistant, July 2021, Volume 31, Issue 7, page 9

Question:

When reporting code 52601, do all procedures referenced in parentheses need to be performed? Or just some of them?

Answer:

The procedures listed in parentheses for code 52601, Transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included), are procedures that would not be coded separately, if performed. These procedures are not required to be performed in order to report code 52601; however, they are not separately reportable, if performed. This code describes prostate resection via transurethral approach using an electrosurgical device and is intended to describe an initial resection of the prostate.