Case Log Coding Guidelines Review Committee for Otolaryngology ACGME The following Case Log Coding Guidelines 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 that was utilized in the development of these guidelines, and the University of Michigan program for the most recent revisions. Please note that these guidelines 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 Review Committee to be representative of otolaryngology surgical education. 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 ACGME e-Communication or other correspondence. 1 ©2012 Accreditation Council for Graduate Medical Education (ACGME) Table of Contents GENERAL/ENDOSCOPY/RHINOLOGY ......................................................................... 2 Emergency Department Procedures ........................................................................... 2 Post-operative Complications ..................................................................................... 3 Endoscopy: Airway and Foreign Body Procedures ..................................................... 3 Sinus Surgery ............................................................................................................. 3 General/Pediatric ........................................................................................................ 4 PEDIATRIC OTOLARYNGOLOGY ................................................................................. 4 LARYNGOLOGY ............................................................................................................ 4 HEAD and NECK SURGERY ......................................................................................... 5 Endocrine Surgery ...................................................................................................... 5 Neck Dissection .......................................................................................................... 5 Salivary Gland Procedures ......................................................................................... 5 Oral Cavity/Oropharynx .............................................................................................. 5 Laryngectomy ............................................................................................................. 6 Anterior Craniofacial Resection ................................................................................... 6 Maxillectomy ............................................................................................................... 6 Excision of Cutaneous Facial Lesion .......................................................................... 6 Head and Neck Ablative Procedures .......................................................................... 6 FACIAL PLASCTIC AND RECONSTRUCTIVE SURGERY ............................................ 7 Free/Pedicled Flaps .................................................................................................... 7 Plastics/Trauma Procedures ....................................................................................... 7 Microtia Repair ............................................................................................................ 8 OTOLOGY/NEUROTOLOGY ......................................................................................... 9 Otology ....................................................................................................................... 9 Ablative Otologic Procedures ...................................................................................... 9 Reconstructive Otologic Procedures ........................................................................... 9 Appendix: Key Indicator Categories ............................................................................. 10 laceration repair: *Asterisk by key indicator cases <1.0 cm: 13150 Rules for unbundling noted in blue 1.1-2.5 cm: 13151 2.6-7.5 cm: 13152 Role Definitions: Each additional 5cm Resident surgeon: performs ≥ 50% of the operation (code separate): 13153 with the attending physician or resident supervisor, Open repair frontal sinus fracture: including the key portions of the procedure Depressed: 21343 Resident assistant: performs < 50% of the operation, Complicated: 21344 or ≥ 50% of the operation but not the key portions of Oral vestibule laceration repair: the procedure. ≤2.5cm: 40830 Resident supervisor: instructs/assists a more junior >2.5cm: 40831 resident during a procedure in which the junior FOM/Oral tongue laceration repair: resident performs ≥ 50% of the operation, including the ≤2.5cm: 41250 key portions of the procedure; the attending physician >2.5cm 41252 acts as an assistant or observer. Flexible laryngoscopy, diagnostic: 31575 Flexible laryngoscopy, w/biopsy: 31576 GENERAL/ENDOSCOPY/RHINOLOGY *Flexible laryngoscopy, FB removal: 31577 * Flexible laryngoscopy, lesion removal: 31577 Emergency Department Procedures: Peritonsillar abscess drainage: 42700 Repair complex scalp laceration: Removal impacted cerumen: 69210 1.1-2.5cm: 13120 Removal foreign body from ear: 69200 2.6-7.5cm: 13121 Under GA (operative): 69205 Each additional 5cm Removal of foreign body from nose: 30300 (code separate): 13122 Under GA (operative): 30310 Repair complex forehead/face laceration: 1.1-2.5cm: 13131 Epistaxis Control 2.6-7.5cm: 13132 Anterior epistaxis control (simple): 30901 Each additional 5cm Anterior epistaxis control (complex): 30903 (code separate): 13133 Posterior packing placement: 30905 Repair complex eyelid/ear/nose or lip Revision posterior packing: 30906 2 ©2012 Accreditation Council for Graduate Medical Education (ACGME) Ethmoid artery ligation: 30915 *Bronchoscopy w/FB removal: 31635 Internal maxillary ligation, transantral: 30920 DL w open reduction of fracture: 31584 Endoscopic control, operative: 31238 *DL with dilation, initial: 31528 Septal hematoma/abscess drainage: 30000 *subsequent: 31529 Auricle hematoma/abscess: 69000 *Bronchoscopy w/dilation: 31630 Oral vestibule drainage of cyst, abscess, *Bronchoscopy w/stent placement: 31631 hematoma: *Revision 31638 Simple: 40800 *Bronchoscopy w/tumor excision: 31640 Complicated 40801 *Bronchoscopy w/tumor or stenosis Intraoral I&D abscess/cyst/hematoma: laser ablation: 31641 Lingual: 41000 *Tracheobronchoscopy through Sublingual; superficial: 41005 tracheostomy incision: 31615 Sublingual; deep: 41006 Esophagoscopy, diagnostic: 43200 Submental: 41007 Esophagoscopy, Submandibular space: 41008 w/submucosal injection: 43201 Sublingual/Submaxillary: 42310 w/biopsy: 43202 Masticator space: 41009 w/tumor removal 43217 Extraoral I&D abscess/cyst/hematoma: w/insertion of stent/tube 43219 Sublingual: 41015 w/dilation over guidewire 43226 Submental: 41016 Esophageal dilation Submandibular space: 41017 w/balloon 43220 Masticator space: 41018 w/bougie: 43450 Parotid abscess I&D; simple: 42300 over guidewire: 43453 Parotid abscess I&D; complicated: 42305 retrograde: 45456 Retropharyngeal/parapharyngeal PEG/ G-tube placement: 43246 abscess I&D; intraoral: 42720 Nasopharyngeal biopsy: 42806 Retropharyngeal/parapharyngeal Zenker’s: abscess I&D; extraoral: 42725 (endoscopic) 43499 (open) 43130 Post-operative Complications: (open cricopharyngeal- Neck exploration for hematoma: 35800 myotomy) 43030 Post-operative tonsil bleed requiring OR: 42962 Transcervical repair of esophageal I&D superficial abscess: 10060 wound/injury (open): 43410 I&D deep space hematoma or abscess: 21501 Sinus Surgery (log each side separately): Endoscopy: Airway/Foreign Body Procedures: Insertion of nasal button: 30220 DL, diagnostic: 31525 Removal of FB; lateral rhinotomy: 30320 DL w/biopsy: 31535 Lysis of intranasal synechiae: 30560 DL w/arytenoidectomy: 31560 Endo maxillary antrostomy: 31256 MicroDL w/arytenoidectomy: 31561 Endo maxillary antrostomy + tissue: 31267 Tracheoscopy or microlaryngoscopy Endo frontal +/- tissue: 31276 with biopsy: 31536 Endo sphenoid: 31287 *Bronchoscopy, diagnostic: 31622 Endo sphenoid + tissue: 31288 *Bronchoscopy with BAL: 31624 Endo biopsy or polyp or debridement: 31237 *Bronchoscopy with biopsy: 31625 Endo concha bullosa: 31240 Awake fiberoptic intubation or DCR: emergency intubation: 31500 Endo 31239 Cricoidotomy: 31605 Open/fistulization 68720 Tracheotomy, planned: 31600 *Endo Ant ethmoid: 31254 Tracheotomy, emergency: 31603 *Endo total ethmoid: 31255 Tracheal repair: 31800 Endo diag., maxillary b inf meatus: 31233 *DL with FB removal: 31530 Endo nasal: 31231 Micro DL, diagnostic: 31526 Endo CSF leak repair: *Micro DL w/FB removal: 31531 Ethmoid region: 31290 Removal FB pharynx: 42809 Sphenoid region: 31291 Esophagoscopy w/FB removal: 43215 CSF leak repair