2016 EAR, NOSE & THROAT (ENT) SURGERY MEDICARE ...

2016 EAR, NOSE & THROAT
(ENT) SURGERY
MEDICARE REIMBURSEMENT
CODING GUIDE

Effective January 1, 2016

Medicare National Average Rates and Allowables

(Not Adjusted for Geography)

PHYSICIAN3 HOSPITAL OUTPATIENT4 ASC4

CPT CODE1/ CODE DESCRIPTION MEDICARE NAT’L AVG APC AND APC MEDICARE MEDICARE
HCPCS CF=$35.8043 DESCRIPTION NAT’L AVG NAT’L AVG
CODE2
FACILITY NON-FACILITY
SETTING SETTING

CERVICAL RESECTION (MODIFIED RADICAL NECK DISSECTION)

38720 Cervical lymphadenectomy (complete) $1,396 NA 5092, Level 2 $3,647 N/A for
Breast/Lymphatic ASC
Surgery and Related
Procedures

38724 Cervical lymphadenectomy (modified radical neck $1,509 NA Inpatient only, not reimbursed for hospital
dissection) outpatient or ASC
60500 PARATHYROID PROCEDURES NA
60502 NA
60505 Parathyroidectomy or exploration of parathyroid(s) $1,000 NA 5165, Level 5 ENT $3,956 $1,994
Procedures $3,956 N/A for
42410 Parathyroidectomy or exploration of parathyroid(s); $1,333 NA 5165, Level 5 ENT ASC
42415 re-exploration $1,435 NA Procedures
42420 Parathyroidectomy or exploration of parathyroid(s); NA
42425 with mediastinal exploration, sternal split or $648 NA Inpatient only, not reimbursed for hospital
42426 transthoracic approach $1,099 NA outpatient or ASC
PAROTID PROCEDURES $1,234
Excision of parotid tumor or parotid gland; lateral $870 5165, Level 5 ENT $3,956 $1,994
lobe, without nerve dissection $1,403 Procedures
Excision of parotid tumor or parotid gland; lateral
lobe, with dissection and preservation of facial 5165, Level 5 ENT $3,956 $1,994
nerve Procedures
Excision of parotid tumor or parotid gland; total,
with dissection and preservation of facial nerve 5165, Level 5 ENT $3,956 $1,994
Excision of parotid tumor or parotid gland; total, en Procedures
bloc removal with sacrifice of facial nerve
Excision of parotid tumor or parotid gland; total, 5165, Level 5 ENT $3,956 $1,994
with unilateral radical neck dissection Procedures

Inpatient only, not reimbursed for hospital
outpatient or ASC

42440 Excision of submandibular (submaxillary) gland $429 NA 5165, Level 5 ENT $3,956 $1,994
Procedures

42450 Excision of sublingual gland $374 $470 5165, Level 5 ENT $3,956 $1,994
42500 $358 $452 Procedures $1,617 $904
42505 Plastic repair of salivary duct, sialodochoplasty; $474 $579 5164, Level 4 ENT $3,956 $1,994
primary or simple Procedures
Plastic repair of salivary duct, sialodochoplasty; 5165, Level 5 ENT
secondary or complicated Procedures

PHYSICIAN3 HOSPITAL OUTPATIENT4 ASC4

CPT CODE1/ CODE DESCRIPTION MEDICARE NAT’L AVG APC AND APC MEDICARE MEDICARE
HCPCS CF=$35.8043 DESCRIPTION NAT’L AVG NAT’L AVG
CODE2
FACILITY NON-FACILITY
SETTING SETTING

42507 PAROTID PROCEDURES CONT’D $538 NA 5165, Level 5 ENT $3,956 $1,994
42509 Parotid duct diversion, bilateral (Wilke type $880 NA Procedures $3,956 $1,994
42510 procedure) 5165, Level 5 ENT $3,956 $1,994
Parotid duct diversion, bilateral (Wilke type $670 NA Procedures
60212 procedure); with excision of both submandibular 5165, Level 5 ENT
60225 glands Procedures
Parotid duct diversion, bilateral (Wilke type
procedure); with ligation of both submandibular $1,042 NA 5361, Level 1 $4,001 $2,011
(Wharton's) ducts $965 NA Laparoscopy

THYROID PROCEDURES 5361, Level 1 $4,001 $2,011
Partial thyroid lobectomy, unilateral; with Laparoscopy
contralateral subtotal lobectomy, including
isthmusectomy
Total thyroid lobectomy, unilateral; with
contralateral subtotal lobectomy, including
isthmusectomy

60240 Thyroidectomy, total or complete $953 NA 5361, Level 1 $4,001 $2,011
Laparoscopy

60252 Thyroidectomy, total or subtotal for malignancy; $1,370 NA 5165, Level 5 ENT $4,001 N/A for
60254 with limited neck dissection NA Procedures ASC
60260 NA
60270 Thyroidectomy, total or subtotal for malignancy; $1,735 NA Inpatient only, not reimbursed for hospital
60271 with radical neck dissection NA outpatient or ASC

Thyroidectomy, removal of all remaining thyroid $1,133 5165, Level 5 ENT $3,956 N/A for
tissue following previous removal of a portion of Procedures ASC
thyroid

Thyroidectomy, including substernal thyroid; sternal $1,417 Inpatient only, not reimbursed for hospital
split or transthoracic approach outpatient or ASC

Thyroidectomy, including substernal thyroid; $1,096 5165, Level 5 ENT $3,956 N/A for
cervical approach Procedures ASC

TONSIL AND ADENOID PROCEDURES

42800 Biopsy; oropharynx $117 $165 5163, Level 3 ENT $690 $106
Procedures

42804 Biopsy; nasopharynx, visible lesion, simple $118 $203 5164, Level 4 ENT $1,617 $904
42806 Biopsy; nasopharynx, survey for unknown primary $138 $228 Procedures $1,617 $904
42809 lesion $127 $210 5164, Level 4 ENT $91 Pkg’d Pmt
42810 Removal of foreign body from pharynx $301 $403 Procedures $1,617 $904
Excision branchial cleft cyst or vestige, confined to $583 5734, Level 4 Minor
42815 skin and subcutaneous tissues $303 NA Procedures $3,956 $1,994
Excision branchial cleft cyst, vestige, or fistula, 5164, Level 4 ENT
42820 extending beneath subcutaneous tissues and/or NA Procedures $1,617 $904
42821 into pharynx NA $1,617 $904
42825 Tonsillectomy and adenoidectomy; under age 12 NA 5165, Level 5 ENT $3,956 $1,994
42826 NA Procedures $1,617 $904
42830 Tonsillectomy and adenoidectomy; age 12 and over $314 NA $3,956 $1,994
5164, Level 4 ENT
Tonsillectomy, primary or secondary; under age 12 $273 Procedures
Tonsillectomy, primary or secondary; age 12 and $262 5164, Level 4 ENT
over $216 Procedures
Adenoidectomy, primary; under age 12 5165, Level 5 ENT
Procedures
5164, Level 4 ENT
Procedures
5165, Level 5 ENT
Procedures

PHYSICIAN3 HOSPITAL OUTPATIENT4 ASC4

CPT CODE1/ CODE DESCRIPTION MEDICARE NAT’L AVG APC AND APC MEDICARE MEDICARE
HCPCS CF=$35.8043 DESCRIPTION NAT’L AVG NAT’L AVG
CODE2
FACILITY NON-FACILITY
SETTING SETTING

TONSIL AND ADENOID PROCEDURES CONT’D

42831 Adenoidectomy, primary; age 12 and over $233 NA 5164, Level 4 ENT $1,617 $904
Procedures

42835 Adenoidectomy, secondary; under age 12 $201 NA 5164, Level 4 ENT $1,617 $904
42836 NA Procedures $1,617 $904
42842 Adenoidectomy, secondary; age 12 and over $251 NA 5164, Level 4 ENT $3,956 N/A for
42844 NA Procedures $3,956 ASC
42860 Radical resection of tonsil, tonsillar pillars, and/or $1,069 NA 5165, Level 5 ENT $3,956 N/A for
42870 retromolar trigone; without closure $1,465 NA Procedures $1,617 ASC
42890 Radical resection of tonsil, tonsillar pillars, and/ NA $3,956 $1,994
or retromolar trigone; closure with local flap (eg, 5165, Level 5 ENT $904
S2900 tongue, buccal) Procedures $1,994

Excision of tonsil tags $196 5165, Level 5 ENT
Procedures
Excision or destruction lingual tonsil, any method $631 5164, Level 4 ENT
(separate procedure) Procedures
5165, Level 5 ENT
Limited pharyngectomy $1,512 Procedures

ROBOTIC ASSISTANCE5 N/A
Surgical techniques requiring use of robotic surgical
system

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; 80 Fed. Reg. 70885-71386: https://www.gpo.gov/fdsys/pkg/FR-2015-11-16/pdf/2015-28005.pdf. Published November 16, 2015. See also the
January 2016 release of the PFS Relative Value File RVU16A at http:/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. 80 Fed. Reg. 70297-70607: http://www.gpo.gov/fdsys/pkg/FR-2015-11-13/pdf/2015-27943.pdf. Published November 13, 2015.
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.

HOSPITAL INPATIENT PIC
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
4: Body Part The two main root operations for removal of tissue are B-Excision and T-Resection. By definition, B-Excision
5: Approach involves removing a portion of the body part and T-Resection involves removing the entire body part.2 For
7: Qualifier 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

This 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.

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

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.

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 SURGERY

DRG Assignment FY2016—effective January 1, 2016

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- MS-DRG TITLE1,2 FY 2016 RELATIVE FY 2016 FY 2016 SUBJECT FY 2016 MEDICARE
DRG1 WEIGHT1 GEOMETRIC MEAN
LENGTH OF STAY1 TO PACT?1,3 NATIONAL AVERAGE4
129
CERVICAL RESECTION (MODIFIED RADICAL NECK DISSECTION)

Major Head and Neck Procedures W CC/MCC or 2.2292 3.7 No $13,166
Major Device

130 Major Head and Neck Procedures W/O CC/MCC 1.3596 2.3 No $8,030

PARATHYROID PROCEDURES

625 Thyroid, Parathyroid and Thyroglossal 2.6133 4.9 No $15,435
Procedures W MCC 1.3936 2.2 No $8,231
0.9108 1.3 No $5,379
626 Thyroid, Parathyroid and Thyroglossal
Procedures W CC

627 Thyroid, Parathyroid and Thyroglossal
Procedures W/O CC/MCC

PAROTID PROCEDURES

139 Salivary Gland Procedures 0.9828 1.6 No $5,805

THYROID PROCEDURES5

625 Thyroid, Parathyroid and Thyroglossal 2.6133 4.9 No $15,435
Procedures W MCC 1.3936 2.2 No $8,231
0.9108 1.3 No $5,379
626 Thyroid, Parathyroid and Thyroglossal
Procedures W CC 1.8573 3.8 No $10,969
1.0635 1.9 No $6,281
627 Thyroid, Parathyroid and Thyroglossal
Procedures W/O CC/MCC

TONSIL AND ADENOID PROCEDURES6

133 Other Ear, Nose, Mouth and Throat OR
Procedures W CC/MCC

134 Other Ear, Nose, Mouth and Throat OR
Procedures W/O CC/MCC

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 FY2016 Rates Final Rule, 80 Fed. Reg. 49325-49843. https://www.gpo.gov/fdsys/pkg/FR-2015-08-
17/pdf/2015-19049.pdf. Published August 17, 2015.
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 ($5,467.39) plus the capital standard amount ($438.75). 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 FY2016 Rates; Correction, 80 Fed. Reg. 60055-60069. Tables 1A-1E. http://www.gpo.gov/fdsys/pkg/FR-2015-10-05/
pdf/2015-25269.pdf. Published October 5, 2015. 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.

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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