Review Committee for Otolaryngology Case Log Coding Recommendations The following Case Log Coding Recommendations have been provided in an attempt to establish some degree of uniformity for all Otolaryngology residents for logging cases into the ACGME Case Log System. The Review Committee for Otolaryngology publicly thanks and credits the Harvard Otolaryngology Residency Program for drafting the initially proposed document which was utilized in the development of these recommendations, and the University of Michigan Program for the most recent revisions. Please note that these recommendations additionally provide role definitions for Resident Surgeon, Resident Assistant, and Resident Supervisor, and demarcate those procedural codes that define Key Indicator Cases (as indicated by red asterisks *). These cases constitute the 14 procedure categories identified by the RRC to be representative of Otolaryngology surgical training. Also included are instructions for the proper un-bundling of procedures (as indicated by blue text) for Case Log recording (but not billing) purposes. This document contains a linkable Table of Contents for electronic use, but is also designed to print in booklet form (pages 2-9). This document will be periodically updated by the Review Committee for Otolaryngology based on updates to key indicator cases and procedures. Program directors will be notified of such updates via the RRC News for Otolaryngology or other correspondence. Table of Contents GENERAL/ENDOSCOPY/RHINOLOGY ......................................................................... 2 Emergency Department Procedures ........................................................................... 2 Postoperative Complications ....................................................................................... 2 Endoscopy: Airway and Foreign Body Procedures ..................................................... 2 Sinus Surgery ............................................................................................................. 3 General/Pediatric ........................................................................................................ 3 PEDIATRIC OTOLARYNGOLOGY ................................................................................. 4 LARYNGOLOGY ............................................................................................................ 4 HEAD & NECK SURGERY ............................................................................................. 4 Endocrine Surgery ...................................................................................................... 4 Neck Dissection .......................................................................................................... 4 Salivary Gland Procedures ......................................................................................... 5 Oral Cavity/Oropharynx .............................................................................................. 5 Laryngectomy ............................................................................................................. 5 Anterior Craniofacial Resection ................................................................................... 5 Maxillectomy ............................................................................................................... 6 Excision of Cutaneous Facial Lesion .......................................................................... 6 Head & Neck Ablative Procedures .............................................................................. 6 FACIAL PLASCTIC AND RECONSTRUCTIVE SURGERY ............................................ 6 Free/Pedicled Flaps .................................................................................................... 6 Plastics/Trauma Procedures ....................................................................................... 6 Microtia Repair ............................................................................................................ 8 OTOLOGY/NEUROTOLOGY ......................................................................................... 8 Otology ....................................................................................................................... 8 Ablative Otologic Procedures ...................................................................................... 8 Reconstructive Otologic Procedures ........................................................................... 9 Appendix: Key Indicator Categories ............................................................................. 10 1 *Asterisk by key indicator cases Epistaxis Control Rules for unbundling noted in blue Anterior epistaxis control (simple): 30901 Anterior epistaxis control (complex): 30903 Role Definitions: Posterior packing placement: 30905 Resident surgeon: performs ≥ 50% of the operation Revision posterior packing: 30906 with the attending physician or resident supervisor, Ethmoid artery ligation: 30915 including the key portions of the procedure Internal maxillary ligation, transantral: 30920 Resident assistant: performs < 50% of the operation, Endoscopic control, operative: 31238 or ≥ 50% of the operation but not the key portions of Septal hematoma/abscess drainage: 30000 the procedure. Auricle hematoma/abscess: 69000 Resident supervisor: instructs/assists a more junior Oral vestibule drainage of cyst, abscess, resident during a procedure in which the junior hematoma: resident performs ≥ 50% of the operation, including the Simple: 40800 key portions of the procedure; the attending physician Complicated 40801 acts as an assistant or observer. Intraoral I&D abscess/cyst/hematoma: Lingual: 41000 GENERAL/ENDOSCOPY/RHINOLOGY Sublingual; superficial: 41005 Sublingual; deep: 41006 Emergency Department Procedures: Submental: 41007 Repair complex scalp laceration: Submandibular space: 41008 1.1-2.5cm: 13120 Sublingual/Submaxillary: 42310 2.6-7.5cm: 13121 Masticator space: 41009 Each additional 5cm Extraoral I&D abscess/cyst/hematoma: (code separate): 13122 Sublingual: 41015 Repair complex forehead/face laceration: Submental: 41016 1.1-2.5cm: 13131 Submandibular space: 41017 2.6-7.5cm: 13132 Masticator space: 41018 Each additional 5cm Parotid abscess I&D; simple: 42300 (code separate): 13133 Parotid abscess I&D; complicated: 42305 Repair complex eyelid/ear/nose or lip Retropharyngeal/parapharyngeal laceration repair: abscess I&D; intraoral: 42720 <1.0 cm: 13150 Retropharyngeal/parapharyngeal 1.1-2.5 cm: 13151 abscess I&D; extraoral: 42725 2.6-7.5 cm: 13152 Each additional 5cm Postoperative Complications: (code separate): 13153 Neck exploration for hematoma: 35800 Open repair frontal sinus fracture: Postoperative tonsil bleed requiring OR: 42962 Depressed: 21343 I&D superficial abscess: 10060 Complicated: 21344 I&D deep space hematoma or abscess: 21501 Oral vestibule laceration repair: ≤2.5cm: 40830 Endoscopy: Airway / Foreign Body Procedures : >2.5cm: 40831 DL, diagnostic: 31525 FOM/Oral tongue laceration repair: DL with biopsy: 31535 ≤2.5cm: 41250 DL w/ arytenoidectomy: 31560 >2.5cm 41252 MicroDL w/ arytenoidectomy: 31561 Flexible laryngoscopy, diagnostic: 31575 Tracheoscopy or microlaryngoscopy Flexible laryngoscopy, w/ biopsy: 31576 with biopsy: 31536 *Flexible laryngoscopy, FB removal: 31577 *Bronchoscopy, diagnostic: 31622 * Flexible laryngoscopy, lesion removal: 31577 *Bronchoscopy with BAL: 31624 Peritonsillar abscess drainage: 42700 *Bronchoscopy with biopsy: 31625 Removal impacted cerumen: 69210 Awake fiberoptic intubation or Removal foreign body from ear: 69200 emergency intubation: 31500 Under GA (operative): 69205 Cricoidotomy: 31605 Removal of foreign body from nose: 30300 Tracheotomy, planned: 31600 Under GA (operative): 30310 Tracheotomy, emergency: 31603 Tracheal repair: 31800 2 *DL with FB removal: 31530 Endo nasal: 31231 Micro DL, diagnostic: 31526 Endo CSF leak repair: *Micro DL with FB removal: 31531 Ethmoid region: 31290 Removal FB pharynx: 42809 Sphenoid region: 31291 Esophagoscopy with FB removal: 43215 CSF leak repair w/ graft: 61618 *Bronchoscopy with FB removal: 31635 (code graft harvest separately) DL w open reduction of fracture: 31584 Endo orbital wall decompression: *DL with dilation, initial: 31528 Medial or inferior wall: 31292 *subsequent: 31529 Medial and Inferior wall: 31293 *Bronchoscopy with dilation: 31630 Endo optic nerve decompression: 31294 *Bronchoscopy with stent placement: 31631 *Revision 31638 Non-Endoscopic Sinus Surgery *Bronchoscopy with tumor excision: 31640 Sinusotomy; frontal: *Bronchoscopy with tumor or stenosis Trephine: 31070 laser ablation: 31641 Transorbital: 31075 *Tracheobronchoscopy through Frontal sinusotomy; obliterative: tracheostomy incision: 31615 Brow incision w/o osteoplastic flap: 31080 Esophagoscopy, diagnostic: 43200 Coronal incision w/o osteoplastic flap: 31081 Esophagoscopy, Brow incision w/ osteoplastic flap: 31084 w/ submucosal injection: 43201 Coronal incision w/ osteoplastic flap: 31085 w/ biopsy: 43202 Frontal sinusotomy; non-obliterative: w/ tumor removal 43217 Brow incision w/ osteoplastic flap: 31086 w/ insertion of stent/tube 43219 Coronal incision w/ osteoplastic flap: 31087 w/ dilation over guidewire 43226 Lavage by canulation; maxillary: 31000 Esophageal dilation Lavage by canulation; sphenoid: 31002 w/ balloon 43220 Sinusotomy; maxillary antrostomy: 31020 with bougie: 43450 Sinusotomy; Caldwell-Luc: 31030 over guidewire: 43453 Sinusotomy; Caldwell-Luc + polyps: 31032 retrograde: 45456 Sinusotomy: