Neck Dissection

Question:

My physician did a total thyroidectomy with a modified radical neck dissection.  Can I report the radical neck dissection with the thyroidectomy?

Answer:

If your physician performed the total thyroidectomy using CPT code 60240 and modified radical neck dissection (38724), both procedures may be reported during the same operative session.  The first listed code on the claim should be CPT 38724. Modifier 59 should be appended to CPT code 60240 (lower RVU) since it is bundled under the National Correct Coding Initiative.

*This response is based on the best information available as of 9/5/24.

Microtia Surgery

Question:

What CPT code is appropriate for creating a cutaneous pocket fashioned for the framework for stage 1 of a microtia surgery? 

Answer:

The appropriate code for creating a cutaneous pocket in the context of stage 1 microtia surgery is CPT 14061 (adjacent tissue transfer).  This code corresponds to the procedure involving creating a cutaneous pocket in the right ear and transferring. The cutaneous pocket is essential for accommodating the framework created during reconstruction.  Since the code is selected based on anatomic location and sq centimeter size be sure to document this information in the operative report. 

*This response is based on the best information available as of 7/11/24.

Cancer Surveillance

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

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

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

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.