Pediatric ENT Consultation

Question:

Our internal compliance team states that our pediatric otolaryngologists should never bill for a consultation. This is because the description in the 2025 CPT states "Services that constitute a transfer of care (i.e. are provided for the management of the patient's entire care or for the care of a specific condition or problem) are reported with the appropriate new or established patient codes." I have explained that when a pediatrician refers a patient to us for ear infections, we give our opinion on what treatment is needed, perform surgery and then send the patient back to the pediatrician. If the patient has another ear infection, we ask that they see their pediatrician for management of the acute infection. I argue that what we do does not constitute a "transfer of care". They suggested I reach out to KZA for clarification. Thank you!

Answer:

CPT 2025 has removed previous language related to "transfer of care" from the consultation code section. Most payors no long accept consultation codes and require you to use problem-oriented E/M codes, but there still a few payors who pay for consults. CPT now emphasizes that consultation codes can be used when the criteria for a consult are met, regardless of whether the patient is new or established.

According to CPT, a consultation is appropriate when:

• A physician requests another physician’s opinion or advice regarding diagnosis or treatment.

• The consulting physician provides that opinion and communicates back to the requesting physician.

• The consulting physician does not assume ongoing care for the condition.

The pediatrician refers the patient for evaluation and possible surgical treatment in your case. Your team provides an expert opinion, performs the surgery, and then returns the patient to the pediatrician for ongoing care. You do not manage the patient’s long-term treatment for recurrent infections. This aligns with the definition of a consultation rather than a transfer of care. The fact that you send the patient back to the referring provider and do not assume continuous management supports your use of consult codes.  It is important to check with your individual payor to determine if they accept consultation codes or if they require problem-oriented E/M codes. 

*This response is based on the best information available as of 11/20/25.

Reshaping of the Internal Nasal Valve Region

Question:

My physician has started doing repairs for nasal valve collapse using low energy radiofrequency. We have been using the unlisted code 30999. Another coder told me that is no longer the correct code. Can you help?

Answer:

There is a CPT code 30469 for reporting remodeling of the nasal airway using low energy temperature controlled radiofrequency which was previously reported with the unlisted code 30999. 

*This response is based on the best information available as of 11/06/25.

Needle Aspiration of Peritonsillar Abscess: Choosing the Correct CPT Code

Question:

Can you explain Peritonsillar Abscess billing 42700 vs 10160? Can we bill and defend 42700 if a provider does an FNA to evacuate a PTA?

Answer:

When a provider performs fine needle aspiration (FNA) to evacuate a peritonsillar abscess (PTA), the correct CPT code to report depends on the intent and technique of the procedure.

If it is truly a FNA and performed for diagnostic purposes, such as collecting a specimen for cytology or pathology, then CPT 10021 (Fine needle aspiration biopsy, without imaging guidance; first lesion) is appropriate.

If the provider uses a needle to evacuate pus from a peritonsillar abscess then this is considered a therapeutic aspiration, and CPT 10160 (Puncture aspiration of abscess, hematoma, bulla, or cyst) is the correct code.

According to CPT Assistant, February 2008, Volume 18, Issue 2, pages 8–9: "From a CPT coding perspective, an incision must be performed in order for an incision and drainage procedure to be reported; an aspiration procedure does not involve an incision.”

Therefore, CPT 42700, which describes incision and drainage of abscess; peritonsillar, is not appropriate unless an actual incision is made into the PTA. 

*This response is based on the best information available as of 10/23/25.

Sleep Endoscopy

Question:

Can I report a nasal endoscopy with a diagnostic drug induced sleep endoscopy?

Answer:

No, when reporting CPT code 42975 for a diagnostic drug induced sleep endoscopy you cannot report a nasal endoscopy 31231 unless it is performed for a separate condition other than sleep disordered breathing and using a separate endoscope.

*This response is based on the best information available as of 10/09/25.

Reporting Modifiers with Unlisted Codes

Question:

Can modifiers be reported with unlisted CPT codes?

Answer:

Yes, modifiers can be appended to unlisted CPT codes.

In 2024, CPT clarified this by updating the introduction guidelines for unlisted procedures and services. These updates were further explained in the January 2024 issue of CPT Assistant, which addressed the new and revised text and the standardization of reporting unlisted CPT codes across the CPT code set.

Illustration of modifiers that may be appropriately applied includes:

• Laterality modifiers – e.g., RT (right), LT (left)

• Bilateral procedure modifier – 50

• Role-based modifiers – e.g., 62 (two surgeons), 80 (assistant surgeon), 82 (assistant surgeon when qualified resident not available), AS (non-physician surgical assistant)

• Multiple or distinct procedure modifiers – e.g., 51 (multiple procedures), 59 (distinct procedural service)

• Global modifiers – e.g., 58 (staged or related procedure), 78 (return to operating room for related procedure), 79 (unrelated procedure or service)

This is not an all-inclusive list of modifiers that may be appropriately applied to unlisted CPT codes. For complete and up-to-date information, one should refer to current CPT guidelines and payer-specific policies.

Please note: Modifiers that describe an alteration of a service or procedure, such as modifier 52 (reduced services), are not appropriate for use with unlisted codes. The same applied to modifier 22 (increased procedural services).

*This response is based on the best information available as of 9/22/25.

Selecting Skull Base Surgical Approaches

Question:

How should we bill for a skull base surgery approach when the surgeon accessed both the middle and posterior cranial fossae (e.g., CPT® 61591 and 61595), and the main lesion was resected from the posterior cranial fossa (e.g., CPT® 61616)?

Answer:

Per CPT® guidelines, codes 61591 and 61595 represent distinct surgical approaches to the middle and posterior cranial fossae, respectively. They do not denote which area of the brain is accessed. Each code includes specific required components:

• 61591 – Infratemporal post-auricular approach to middle cranial fossa (internal auditory meatus, petrous apex, tentorium, cavernous sinus, parasellar area, infratemporal fossa) including mastoidectomy, resection of sigmoid sinus, with or without decompression and/or mobilization of contents of auditory canal or petrous carotid artery

• 61595 – Transtemporal approach to posterior cranial fossa, jugular foramen or midline skull base, including mastoidectomy, decompression of sigmoid sinus and/or facial nerve, with or without mobilization

To report both codes, the operative note must clearly support that all required elements of each code were performed as separate and distinct procedures. Importantly, the mastoidectomy is not optional in either code, and the work on the sigmoid sinus must be a resection for 61591 and decompression for 61595. If these elements overlap or are not separately performed, reporting both codes is not supported.

The middle and posterior cranial fossae are anatomically adjacent, and surgical access to one may involve access to the other. Traversing the middle fossa to reach a posterior lesion does not, by itself, justify reporting a separate middle fossa approach code.

In cases involving resection of a vestibular schwannoma, CPT® instructs coders to use the traditional combined approach and resection codes (61520, 61526, or 61530) rather than the skull base code sets (61580–61619). These codes bundle the approach and resection into a single code and are generally more appropriate for cerebellopontine angle tumors like vestibular schwannomas.

If the lesion is confined to the posterior fossa and the middle fossa was only used as a surgical corridor, then 61595 alone is appropriate. Modifier -22 may be considered if additional complexity is well-documented.

While CPT® does not explicitly prohibit reporting two approach codes, it emphasizes the following principles:

• Duplicative work must be avoided

• Each code must be fully supported by documentation

• Overlapping anatomical access does not justify separate approach or resection codes

If documentation does not support all elements of both codes, and duplication exists, then the coding is not clinically supported. In such cases, CPT® guidance suggests that an unlisted procedure code may be more appropriate.

*This response is based on the best information available as of 9/25/25.