# bundling issue



## efuhrmann

An insurance company(not Medicare) is bundling 31240 with 31267.  The documentation supports both procedures being performed: "left maxillary antrostomy with tissue removal" and "left concha bullosa reduction".  I would like to cite a reference in my appeal, however ENT is not a specialty I am very confident in appealing.  Can someone shed some light for me?


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## jackjones62

What turbinate was the concha bullosa reduced in? inferior, middle or superior?  and is your operative report well documented?

Need more info....

Jennifer
CT ENT


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## efuhrmann

...the airways were improved and now I could visualize the middle turbinate.  The middle turbinate and lateral nasal wall were injected with 0.5% lidocaine with epinephrine, and the middle meatus was treated with cocaine-soaked pledgets.  The attachment of the middle turbinate to the cribriform plate was very fragile and floppy.  I decided not to perform a resection to avoid manipulation of this connection.  The concha bullosa was simply treated by crushing the medial and lateral sidewalls of the concha together using a straight alligator and Takahashi forceps.
The uncinate process was then removed using a backbiter and a 4-mm sinus shaver.  The maxillary antrum was entered using a curved suction.  Soft tissue was impeding the normal os.  This was removed using the 4-mm shaver and a straight biter."

To answer the original question, concha bullose in middle turbinate.


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## jackjones62

Thank you for the op note descriptive, unfortunately, it is what I suspected, the middle turbinate and also the surgeon indicated that the concha bullosa was "simply" treated, they even state they did not [perform a "resection" due to the condition of it; CPT 31240 indicates w/concha bullosa resection, you do not have adequate documentation to support your appeal.

When it comes to the middle turbinate, it is the philosophy of the insurance community that it is inherent to CPT 31256 & 31267, that it is usually excised, resected or reduced to gain access to the maxillary sinus, even though there is no CCI edit, they still will not pay the majority of the time; also, you have to look at CPT itself, who changed it's language with the turbinectomy codes to specifically indicate "inferior" turbinates and excluded the middle turbinates all together.  If this was an inferior turbinate or your surgeon actually resected and did a significant amount of work on that middle turbinate, I would advise you to appeal, but at present your documentation will work against you.

Any one else with an opinion, please respond...

Jennifer
CT ENT

Hope this helps


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## efuhrmann

thanks for the detailed explanation..I appreciate you taking the time for a busy Monday.  Liz


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## tlivengo

Q: Is it appropriate to bill for resection of a concha bullosa with other turbinate procedures?

A: Yes, under certain circumstances which require a detailed review of the operative note. It is important to remember these elements:



When the middle turbinate becomes pneumatized, or filled with air, the term concha bullosa is applied. CPT code 31240 (Nasal/sinus endoscopy, surgical; with concha bullosa resection) is employed for an endoscopic resection of a concha bullosa. 
Excision of the middle turbinate without use of endoscopes is reported with 31299. 
Excision of the middle turbinate without the presence of a concha bullosa and with endoscopic ethmoidectomy is considered integral to the endoscopic ethmoidectomy. In this case, do not report it separately. 
CPT codes 30130 and 30140 specify the inferior turbinates. 
If the surgeon performs CPT 31240 with CPT 30130 or CPT 30140 on the same (or opposite) side(s), both are billable. Modifier -59 should not be necessary but could be appended if needed to over-ride inappropriate bundles.

Many third party payers inappropriately bundle endoscopic concha bullosa resection with the turbinate excision or submucous resection codes. This occurs if the insurer does not realize that the procedures were performed on separate turbinates. These procedures are not bundled in the National Correct Coding Initiative (NCCI) edits. You should appeal denied claims for turbinate surgery when your operative notes adequately document separate procedures.

Revised April 2009


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## tlivengo

I just posted the above answer to your question and forgot to put that I copied and pasted it off of the American Academy of Otolaryngolgy--Head and Neck Surgery website...


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## cpuentes

*Bundled Codes*

I am receiving denials for procedure code 96040 (Med Gen Coun) with office visits for Medicaid HMO's such as Driscoll, Molina, UHC COMM and Superior and  as per TMHP guidelines this code is payable. Is there any information I can submitt to get my appeals to pay correctly.


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