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Cancer Surveillance
When a patient comes in for head and neck cancer surveillance with severe xerostomia because of radiation therapy, and the physician does a complete workup for the xerostomia, and there is detailed documentation about the xerostomia, can we bill an E/M service along with the flexible laryngoscopy (31575)?
Question:
When a patient comes in for head and neck cancer surveillance with severe xerostomia because of radiation therapy, and the physician does a complete workup for the xerostomia, and there is detailed documentation about the xerostomia, can we bill an E/M service along with the flexible laryngoscopy (31575)?
Answer:
If the patient is seen for follow-up for head and neck cancer and they are also being treated for xerostomia you would be able to report a separate E/M service as long as the workup for the xerostomia is documented and treated or there is a change in plan of care to support the evaluation and management service.
*This response is based on the best information available as of 6/20/24.
Cryoablation
I was told we still need to use the unlisted code 30999 for cryoablation of the nasal nerve.
Question:
I was told we still need to use the unlisted code 30999 for cryoablation of the nasal nerve.
Answer:
You no longer report cryoablation of the nasal nerve with an unlisted code. In 2024, a new code was created to report Nasal cryotherapy (31243), also known as nasal cryoablation or cold therapy, as a noninvasive treatment to stop symptoms of chronic rhinitis.
*This response is based on the best information available as of 6/6/24.
Suctioning Debris from the Ear Canal
I just suctioned debris from the ear canal as there was no impacted cerumen. Can I still use 69210?
Question:
I just suctioned debris from the ear canal as there was no impacted cerumen. Can I still use 69210?
Answer:
No. CPT 69210 is specifically for removing impacted cerumen. There is no CPT code for suctioning an ear canal of debris (e.g., Swimmer’s ear, otitis externa). You would report an E/M code and you could also report 92504 if you used the microscope to suction the ear canal.
*This response is based on the best information available as of 5/23/24.
Cerumen Removal
Is the microscope considered “instrumentation” for 69210?
Question:
Is the microscope considered “instrumentation” for 69210?
Answer:
No. The microscope is for visualization, magnification, and/or illumination. It is not an instrument used to remove cerumen as required for 69210. You must use and document an instrument such as suction, curette, right-angle hook, etc. to support using 69210.
*This response is based on the best information available as of 5/9/24.
Biopsy of Ear
What CPT code should I report for an excisional biopsy of the external ear?
Question:
What CPT code should I report for an excisional biopsy of the external ear?
Answer:
The correct code to use is 69100.
*This response is based on the best information available as of 4/25/24.
Post Operative Infection
What CPT code would I use for an I&D of a complicated postoperative wound infection?
Question:
What CPT code would I use for an I&D of a complicated postoperative wound infection?
Answer:
The correct CPT code is 10180 (Incision and drainage, complex postoperative wound infection).
*This response is based on the best information available as of 4/11/24.