Effective ENT Coding Strategies Can Stem Losses from Physician Fee Schedule Cuts

The Physician Fee Schedule Final Rule that the Centers for Medicare and Medicaid Services released November 2 brings two unwelcome payment cuts for otolaryngologists. The cuts aren’t a surprise, but they’re still a disappointment.

The rule provides welcome increases for primary care, but it does so at the expense of specialties like otolaryngology. CMS believes that primary care physicians have been underpaid for coordinating care.

The agency has even created a new add-on code for primary care. HCPCS code G2211 recognizes “the inherent costs involved when clinicians are the continuing focal point for all needed services, or are part of ongoing care related to a patient’s single, serious condition or a complex condition,” CMS explains in its overview of the final rule.

This additional payment for primary care “has redistributive impacts for all other CY 2024 payments under the Medicare Physician Fee Schedule, due to statutory budget neutrality requirements,” CMS observes.

The redistribution accounts for the reduction in the conversion factor from the current $33.89 to a lower $32.74, a decrease of $1.15 (or 3.4%). This is a blow to already stretched otolaryngology practices.

Reimbursement is down and costs are up.

The stress on otolaryngologists and other specialty physician practices is coming from two directions. While reimbursements are down, the costs of providing care have been increasing for years.

Physician office staff are spending approximately 14 hours per week per physician chasing down prior authorizations according to a recent AMA survey. In addition, according to the MGMA, 89% of practices are seeing rising administrative costs.

Less than 10 percent of Medicare money goes to physicians, AAO-HNS EVP and CEO James C. Dennehy III, MD, FACS said at an SCSOHNS conference earlier this year. “When I started in this business it was 20 percent,” Dr. Dennehy recalled. Practices need more and more administrators to deal with payors, EMR implementation costs, and ever-increasing regulations.

ENT Practice Profits Don’t Have to Suffer

We reached out to Barbara Cobuzzi, CEO of CRN Solutions and Consulting Editor for AAPC’s Otolaryngology Coding Alert, for these tips on keeping your practice profitable.

Don’t be afraid to append modifier 25, when warranted, while performing E&M with a minor procedure.

While diagnostic procedures in most specialties are often preplanned, that is not always the case in otolaryngology. Otolaryngologists often perform unplanned diagnostic endoscopies during E&M encounters, Cobuzzi says.

Examples include a diagnostic nasal endoscopy for nasal and sinus complaints (CPT^® code 31231), a nasopharyngoscopy for eustachian and nasopharynx complaints (92511), and laryngoscopy (31575) for complaints involving the throat. These services come with pre- and post-service evaluation time. If all the time and services are documented and coded correctly, appending modifier -25 can help compensate the physician for the complexity of, and the work involved in performing, the procedure performed.

Scrutinize your FESS reimbursements.

ENT auditors have been seeing a lot of mistakes on the payer side when reimbursing for multiple functional endoscopic sinus surgery, Cobuzzi says. The confusion is around CPT^® code 31231, Nasal endoscopy diagnostic, unilateral or bilateral. Even if this procedure is performed on both sides, the bilateral modifier 50 is not used because this code is defined as unilateral or bilateral.

Other functional endoscopic sinus surgeries are coded with a 50 modifier and worth 150 percent of the RVUs (Relative Value Units). When applying the multiple endoscopy rule, payers should be subtracting one times the RVUs assigned to the base code, 31231, because it cannot be coded or billed as a bilateral code.

Unfortunately, reimbursement experts have seen payers erroneously subtracting 150 percent of the RVUs assigned to 31231, therefore deducting too many RVUs from bilateral FESS using the multiple endoscopy rule, Cobuzzi says.