2015 Ear, Nose and Throat (ENT) Surgery
Medicare Reimbursement Coding Guide
Effective January 1, 2015
Medicare National Average Rates and Allowables
(Not Adjusted For Geography)
Physician
CPT™*
HCPCS
Code
Procedure Description
AMBULATORY
SURGICAL
CENTER
HOSPITAL OUPATIENT
*MPFS
(CF=$35.7547)
Fac/Non-Fac
APC
Classification
APC
Descriptor
**APC
Rate
***ASC
Excision Lymphatic
System
$2,344.50
Not reimbursed in
ASC by Medicare
CERVICAL RESECTION
38720
Cervical lymphadenectomy (complete)
$1,387.64
0113
38724
Cervical lymphadenectomy (modified radical neck dissection)
$1,501.70
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
PARATHYROID
60500
Parathyroidectomy or exploration of parathyroid(s);
$995.77
0256
Level VI ENT
Procedures
$3,730.03
$2,043.89
60502
Parathyroidectomy or exploration of parathyroid(s);
re-exploration
$1,329.72
0256
Level VI ENT
Procedures
$3,730.03
Not reimbursed in
ASC by Medicare
60505
Parathyroidectomy or exploration of parathyroid(s); with
mediastinal exploration, sternal split or transthoracic
approach
$1,433.76
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
PAROTID
42410
Excision of parotid tumor or parotid gland; lateral lobe,
without nerve dissection
$643.58
0256
Level VI ENT
Procedures
$3,730.03
$2,043.89
42415
Excision of parotid tumor or parotid gland; lateral lobe, with
dissection and preservation of facial nerve
$1,094.09
0256
Level VI ENT
Procedures
$3,730.03
$2,043.89
42420
Excision of parotid tumor or parotid gland; total, with
dissection and preservation of facial nerve
$1,229.25
0256
Level VI ENT
Procedures
$3,730.03
$2,043.89
42425
Excision of parotid tumor or parotid gland; total, en bloc
removal with sacrifice of facial nerve
$865.62
0256
Level VI ENT
Procedures
$3,730.03
$2,043.89
42426
Excision of parotid tumor or parotid gland; total, with
unilateral radical neck dissection
42440
Excision of submandibular (submaxillary) gland
$427.27
0256
Level VI ENT
Procedures
$3,730.03
$2,043.89
42450
Excision of sublingual gland
$373.28 /
$469.82
0256
Level VI ENT
Procedures
$3,730.03
$2,043.89
42500
Plastic repair of salivary duct, sialodochoplasty; primary or
simple
$356.12 /
$449.79
0254
Level V ENT
Procedures
$1,946.20
$1,066.43
$1,399.80
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
Page 1 of 5
2015 Reimbursement Guide
Ear, Nose and Throat (ENT) Surgery
Page 2 of 5
Physician
AMBULATORY
SURGICAL
CENTER
HOSPITAL OUPATIENT
CPT™*
HCPCS
Code
Procedure Description
*MPFS
(CF=$35.7547)
Fac/Non-Fac
APC
Classification
APC
Descriptor
**APC
Rate
***ASC
42505
Plastic repair of salivary duct, sialodochoplasty; secondary or
complicated
$470.89 /
$576.01
0256
Level VI ENT
Procedures
$3,730.03
$2,043.89
42507
Parotid duct diversion, bilateral (Wilke type procedure);
$531.67
0256
Level VI ENT
Procedures
$3,730.03
$2,043.89
42509
Parotid duct diversion, bilateral (Wilke type procedure); with
excision of both submandibular glands
$875.63
0256
Level VI ENT
Procedures
$3,730.03
$2,043.89
42510
Parotid duct diversion, bilateral (Wilke type procedure); with
ligation of both submandibular (Wharton’s) ducts
$651.45
0256
Level VI ENT
Procedures
$3,730.03
$2,043.89
ROBOTIC ASSISTANCE
S2900‡
Surgical techniques requiring use of robotic surgical system
(list separately in addition to code for primary procedure)
Not Valid for Medicare
THYROID
60212
Partial thyroid lobectomy, unilateral; with contralateral
subtotal lobectomy, including isthmusectomy
$1,041.18
0114
Thyroid/
Lymphadenectomy
Procedures
$4,239.61
$2,323.12
60225
Total thyroid lobectomy, unilateral; with contralateral
subtotal lobectomy, including isthmusectomy
$962.16
0114
Thyroid/
Lymphadenectomy
Procedures
$4,239.61
$2,323.12
60240
Thyroidectomy, total or complete
$948.57
0114
Thyroid/
Lymphadenectomy
Procedures
$4,239.61
$2,323.12
60252
Thyroidectomy, total or subtotal for malignancy; with limited
neck dissection
$1,362.61
0256
Level VI ENT
Procedures
$3,730.03
Not reimbursed in
ASC by Medicare
60254
Thyroidectomy, total or subtotal for malignancy; with radical
neck dissection
$1,730.89
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
60260
Thyroidectomy, removal of all remaining thyroid tissue
following previous removal of a portion of thyroid
$1,128.06
0256
60270
Thyroidectomy, including substernal thyroid; sternal split or
transthoracic approach
$1,414.46
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
60271
Thyroidectomy, including substernal thyroid; cervical
approach
$1,091.59
0256
Level VI ENT
Procedures
$3,730.03
Not reimbursed in
ASC by Medicare
Level VI ENT
Procedures
$3,730.03
Not reimbursed in
ASC by Medicare
TONSIL AND ADENOID
42800
Biopsy; oropharynx
$116.56 /
$164.47
0252
Level III ENT
Procedures
$646.66
$105.12
42804
Biopsy; nasopharynx, visible lesion, simple
$117.63 /
$201.66
0253
Level IV ENT
Procedures
$1,266.86
$694.18
42806
Biopsy; nasopharynx, survey for unknown primary lesion
$136.94 /
$226.33
0254
Level V ENT
Procedures
$1,946.20
$1,066.43
42809
Removal of foreign body from pharynx
$138.37 /
$179.49
0420
Level III Minor
Procedures
$131.75
Packaged Service/
Item
42810
Excision branchial cleft cyst or vestige, confined to skin and
subcutaneous tissues
$299.08 /
$401.88
0254
Level V ENT
Procedures
$1,946.20
$1,066.43
42815
Excision branchial cleft cyst, vestige, or fistula, extending
beneath subcutaneous tissues and/or into pharynx
$581.01
0256
Level VI ENT
Procedures
$3,730.03
$2,043.89
42820
Tonsillectomy and adenoidectomy; younger than age 12
$300.34
0254
Level V ENT
Procedures
$1,946.20
$1,066.43
42821
Tonsillectomy and adenoidectomy; age 12 or over
$311.78
0254
Level V ENT
Procedures
$1,946.20
$1,066.43
42825
Tonsillectomy, primary or secondary; younger than age 12
$271.02
0256
Level VI ENT
Procedures
$3,730.03
$2,043.89
42826
Tonsillectomy, primary or secondary; age 12 or over
$260.29
0254
Level V ENT
Procedures
$1,946.20
$1,066.43
2015 Reimbursement Guide
Ear, Nose and Throat (ENT) Surgery
Page 3 of 5
Physician
CPT™*
HCPCS
Code
Procedure Description
AMBULATORY
SURGICAL
CENTER
HOSPITAL OUPATIENT
*MPFS
(CF=$35.7547)
Fac/Non-Fac
APC
Classification
APC
Descriptor
**APC
Rate
***ASC
42830
Adenoidectomy, primary; younger than age 12
$215.24
0256
Level VI ENT
Procedures
$3,730.03
$2,043.89
42831
Adenoidectomy, primary; age 12 or over
$231.33
0254
Level V ENT
Procedures
$1,946.20
$1,066.43
42835
Adenoidectomy, secondary; younger than age 12
$200.23
0254
Level V ENT
Procedures
$1,946.20
$1,066.43
42836
Adenoidectomy, secondary; age 12 or over
$249.57
0254
Level V ENT
Procedures
$1,946.20
$1,066.43
42842
Radical resection of tonsil, tonsillar pillars, and/or retromolar
trigone; without closure
$1,031.88
0256
Level VI ENT
Procedures
$3,730.03
Not reimbursed in
ASC by Medicare
42844
Radical resection of tonsil, tonsillar pillars, and/or retromolar
trigone; closure with local flap (eg, tongue, buccal)
$1,419.10
0256
Level VI ENT
Procedures
$3,730.03
Not reimbursed in
ASC by Medicare
42860
Excision of tonsil tags
$195.58
0256
Level VI ENT
Procedures
$3,730.03
$2,043.89
42870
Excision or destruction lingual tonsil, any method (separate
procedure)
$599.61
0254
Level V ENT
Procedures
$1,946.20
$1,066.43
42890
Limited pharyngectomy
$1,460.58
0256
Level VI ENT
Procedures
$3,730.03
$2,043.89
NOTES:
• ‡S-Codes are not valid for Medicare payment
• Multiple Procedure Discounting – Multiple surgical procedures furnished during the same operative session are discounted. 50% is paid for any other surgical procedure(s) performed at the same time.
• MPFS Facility allowables and ASC rates include patient cost-sharing (coinsurance and deductibles). HOPPS rates include patient cost-sharing (co-payments and deductibles). These amounts are national averages and are not adjusted for
geography.
• The above 2015 MPFS payment rates reflect policies finalized in the CY 2015 Medicare Physician Fee Schedule Final Rule, CMS-1612-FC that was placed on display at the Federal Register on October 31st, 2014. These rates reflect a zero
percent update effective January 1st, 2015 through March 31st, 2015, as provided for by the Protecting Access to Medicare Act of 2014. The CF published in the January update is $35.7547. Current law requires physician fee schedule
rates to be reduced by an average of 21.2 percent from the CY 2014 rates because of the existing SGR factor used to calculate the conversion factor. In most prior years, Congress has taken action to avert a large reduction in MPFS rates
before they went into effect. Without further congressional action, this updated CF is due to expire on March 31st, 2015.
• The above National Average APC and ASC Rates represent the reimbursement amounts paid directly to the facility for the technical portion of the procedure. The Physician (surgeon) would separately receive the professional fee (MPFS
Allowable) for the procedure performed.
• Rates referenced in this guide do not reflect Sequestration, automatic reductions in federal spending that result in a 2% across-the-board reduction to all Medicare rates.
REFERENCES:
*PFS Relative Value Files, RVU15B (2-13-15), effective April 1, 2015
**CMS-1613-CN (2-24-15) HOPPS Addendum A and B, effective January 1, 2015
***CMS-1613-CN (2-24-15) ASC Addendum AA, BB, DD1, DD2, and EE, effective January 1, 2015
‡CMS 2015 Alpha-Numeric HCPCS File Updated – 11/12/2014
ICD-9-CM Volume 3 Hospital Procedure Codes
Procedure
Code*
Description
CERVICAL RESECTION
40.40
Radical neck dissection, not otherwise specified
40.41
Radical neck dissection, unilateral
40.42
Radical neck dissection, bilateral
PARATHYROID
6.81
Complete parathyroidectomy
6.89
Other parathyroidectomy
PAROTID
26.30
Sialoadenectomy, not otherwise specified
26.31
Partial sialoadenectomy
26.32
Complete sialoadenectomy
ROBOTIC ASSISTANCE
17.41
Open robotic assisted procedure
17.42
Laparoscopic robotic assisted procedure
2015 Reimbursement Guide
Ear, Nose and Throat (ENT) Surgery
Procedure
Code*
Page 4 of 5
Description
17.43
Percutaneous robotic assisted procedure
17.44
Endoscopic robotic assisted procedure
17.45
Thoracoscopic robotic assisted procedure
17.49
Other and unspecified robotic assisted procedure
THYROID
6.11
Closed [percutaneous] [needle] biopsy of thyroid gland
6.12
Open biopsy of thyroid gland
6.13
Biopsy of parathyroid gland
6.19
Other diagnostic procedures on thyroid and parathyroid
glands
6.2
Unilateral thyroid lobectomy
6.31
Excision of lesion of thyroid
6.39
Other partial thyroidectomy
6.4
Complete thyroidectomy
6.50
Substernal thyroidectomy, not otherwise specified
6.51
Partial substernal thyroidectomy
6.52
Complete substernal thyroidectomy
6.6
Excision of lingual thyroid
6.7
Excision of thyroglossal duct or tract
TONSIL AND ADENOID
28.1
Diagnostic procedures on tonsils and adenoids
28.2
Tonsillectomy without adenoidectomy
28.3
Tonsillectomy with adenoidectomy
28.4
Excision of tonsil tag
28.5
Excision of lingual tonsil
28.6
Adenoidectomy without tonsillectomy
NOTES:
The ICD-9-CM Hospital Procedure Codes listed above may be used in the MS-DRG Classifications (See Inpatient DRG Payment Rates Table)
The appropriate MS-DRG classification is also dependent on the diagnosis code, demographics, sex and possible co-conditions.
REFERENCES:
*2015 Hospital ICD-9-CM Volume 3, 9th Revision, Clinical Modification, Sixth Edition
INPATIENT DRG PAYMENT RATES
MS-DRG*
MS-DRG Title
Arithmetic Mean
Length of Stay
(Days)
National
Average
Payment**
CERVICAL RESECTION
129
Major Head and Neck procedures w/ CC/MCC or Major Device
5.4
$13,674.27
130
Major Head and Neck procedures w/o CC/MCC
2.8
$7,399.17
PARATHYROID
625
Thyroid, Parathyroid and Thyroglossal Procedures w/ MCC
7.1
$14,620.97
626
Thyroid, Parathyroid and Thyroglossal Procedures w/CC
3.1
$7,681.65
627
Thyroid, Parathyroid and Thyroglossal Procedures w/o CC/MCC
1.5
$5,087.62
PAROTID
139
Salivary Gland Procedures
2.1
$5,788.25
625
Thyroid, Parathyroid and Thyroglossal Procedures w/ MCC
7.1
$14,620.97
626
Thyroid, Parathyroid and Thyroglossal Procedures w/CC
3.1
$7,681.65
627
Thyroid, Parathyroid and Thyroglossal Procedures w/o CC/MCC
1.5
$5,087.62
7.1
$14,620.97
THYROID
625
Thyroid, Parathyroid and Thyroglossal Procedures w/ MCC
2015 Reimbursement Guide
Ear, Nose and Throat (ENT) Surgery
MS-DRG*
Page 5 of 5
MS-DRG Title
Arithmetic Mean
Length of Stay
(Days)
National
Average
Payment**
626
Thyroid, Parathyroid and Thyroglossal Procedures w/CC
3.1
$7,681.65
627
Thyroid, Parathyroid and Thyroglossal Procedures w/o CC/MCC
1.5
$5,087.62
TONSIL AND ADENOID
133
Other Ear, Nose, Mouth and Throat O.R. Procedures w/ CC MCC
5.4
$10,949.29
134
Other Ear, Nose, Mouth and Throat O.R. Procedure w/o CC MCC
2.4
$5,921.56
NOTES:
*One DRG per patient is assigned to each inpatient stay.
REFERENCES:
** FY 2015 Final Rule, Federal Register, Vol. 79, No. 163, Friday, August 22, 2014 and Correction Notice, Federal Register, Vol. 79, No. 192, Friday, October 3, 2014, Table 1A-1E and Table 5. National Average Payment Rate is based upon the
National Average Operating Standardized Amount ($5,437.85) plus the Capital Standard Federal Payment Rate ($434.97).
Disclaimer:
The information contained in this guide is provided to help you understand the reimbursement process. It is not intended to increase or maximize reimbursement by any
payer. We strongly recommend that providers consult their payer organization with regard to local reimbursement policies. The information contained in this guide is
provided for information purposes only and represents no statement, promise or guarantee by Covidien concerning levels of reimbursement, payment or charge.
Similarly, all CPT HCPCS and ICD-9-CM codes are supplied for information purposes only and represent no statement, promise or guarantee by Covidien that these codes
will be appropriate or that reimbursement will be made. ICD-9-CM is based on the official version of the World Health Organization’s Ninth Revision, International Classification of Diseases. CPT codes and descriptions only are copyright 2013 American Medical Association. All rights reserved.
CPT does not include fee schedules, relative values or related listings. The source for this information is the Centers for Medicare and Medicaid Services (CMS). Reimbursement rates reflected in this guide are Medicare National Average rates as published by CMS at the time of printing, and do not reflect provider payment adjustment factors
such geographic adjustment, participation as a Disproportionate Share or Teaching Hospital, participation in the CMS Shared Service (ACO) program, or Value Base Purchasing adjustments. The content provided by CMS is updated frequently. It is the responsibility of the health services provider to confirm the appropriate coding required
by their local Medicare Administrative Contractors (MACs), carriers, fiscal intermediaries and commercial payers.
All Current Procedural Terminology (CPT) five-digit numeric codes, descriptions, numeric modifiers, instructions, guidelines and other material are copyright © 2014
American Medical Association. All rights reserved.
Code associations and values have been reviewed and validated by NMD Healthcare, Inc.
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