Medicare Compliance & Reimbursement

It works: Empire Medicare covers rhinometry thanks to this coder's digging

If you shudder at the sight of rhinometry denials, we've got the answers you need to glide through your next claim on your first try.

Consider this acoustic rhinometry (AR) case study. One coder reveals the documentation she used to overturn an insurer's view of the test as experimental. Including this documentation with your claim could help you avoid
a denial.

The service: Physicians are using new diagnostic test to evaluate chronic rhinitis (472.0), notes physician David Plaxico with Allergy & Asthma Clinic of Macon in Georgia.

Many insurers have policies that deem rhinometry experimental and investigational. For instance, Aetna won't cover 92512 (Nasal function studies [e.g., rhinomanometry]) in part because "clinical studies have not demonstrated that rhinomanometry and acoustic rhinometry improve clinical outcomes," according to Aetna's "Clinical Policy Bulletin: Rhinomanometry and Acoustic Rhinometry" (visit www.aetna.com/cpb/medical/data/700_799/0700.html).

But showing payors a series of documents might make them change their tune.

Step 1: Show That Related Devices Are FDA-Approved

In the battle for 92512 coverage, expect insurers to first want evidence that the device is a Food and Drug Administration-approved product. Before covering 92512, Empire Blue Cross Blue Shield (Medicare Part B for New Jersey and New York state) required such proof, says Laura Colbert Carbonaro, director of central billing operations for ENT and Allergy Associates in Tarrytown, NY.

A phone call to the FDA resulted in a letter pointing Carbonaro to the documentation Empire BCBS required. "E. Benson Hood Lab Inc. received FDA marketing clearance on July 26, 2002, for their rhinoanemometer (FDA #K011329)," confirmed Bonnie J. Alderton, public health adviser at the FDA's Center for Devices and Radiological Health.

Even better: Alderton identified the Web site of a copy of the clearance letter the FDA sent the firm upon clearing its device, which you can use in your fight. Find it at www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPMN/pmn.cfm?ID=4403.

Step 2: Tell the Payor What The Service Is

You can't hope to convince an insurer to cover a test if the representative has no clue what the device is.

Solution: Provide a low-key explanation of rhinometry, such as this definition: "Acoustic rhinometry (AR) is a quick, painless, noninvasive and reproducible method for examination of the nasal cavity using a sound pulse technique," write the medical authors of "An Interpretation Method for Objective Assessment of Nasal Congestion With Acoustic Rhinometry" in Laryngoscope, 112: 926-929, 2002.

Step 3: Illustrate the Benefits of the Service

Carbonaro didn't stop there. She also gathered information supporting the benefits of acoustic rhinometry in a ready-to-go package. To make an insurance representative reconsider his company's policy that 92512 is noncovered as investigational or experimental, point to the following scholarly article that demonstrates rhinometry's efficacy.

An acoustic rhinometry study conducted by the authors of the aforementioned Laryngoscope article found test readings allowed physicians to grade the congestion state of the nasal cavity "for objective evaluation of nasal congestion."

Acoustic rhinometry has been shown to provide true "cross-sectional areas of the nose," say physicians Vincent W. S. Lai and Jacquelynne P. Corey in "The Objective Assessment of Nasal Patency." A highly significant correlation exists between the minimal cross-sectional area and the subjective feeling of nasal patency.

By determining which anatomic structure contributes to the minimal cross-sectional area, as well as determining how this changes after decongestion, the otolaryngologist can identify the pathological factor(s) that are causing symptoms.

Step 4: Show The Service Helps Treatment Choice

As to payors that refuse 92512 payment due to unproven clinical outcomes, give the naysayers this food for thought: AR can assess "the effectiveness of treatment including pharmacotherapy and immunotherapy, as well as surgical outcomes," Lai and Corey say.

Case 1: The physicians use an AR reading and documentation to identify the anatomic reason for a patient's nasal obstruction: the inferior turbinate. When the ENT compares the pre- to the post-decongestion reading, he can determine that the patient's problem is a reversible mucosal disorder, allergic rhinitis, meaning medication and possibly allergen immunotherapy--not surgery--may be the best route.

Tip: Tell the carrier an AR payment could save the insurer money down the road by suggesting in-office treatment instead of surgical intervention. Because nasal patency is otherwise rather subjective, AR offers a useful tool.

Case 2: AR can also evaluate nasopharyngeal pathology and plate movement. Readings before and after septoplasty and turbinate reduction allow the ENT to assess the surgery's effectiveness, Lai and Corey show.

An Otolaryngology--Head and Neck Surgery article confirms this benefit: "Acoustic rhinometry is valuable in objectively confirming nasal patency after nasal septal and turbinate surgery," according to "Preoperative and Postoperative Nasal Septal Surgery Assessment With Acoustic Rhinometry" (1997, 117: 338-42).

Step 5: Argue, 'They're Covering It'

Experts often say that the best method to convince an insurer to cover a service is to point out that bigger fish are doing so. That's exactly what Carbonaro did.

Once Empire BCBS covered 92512, Carbonaro told other insurers about the carrier's stance. "I've used [Empire's coverage policy] in appeals with smaller carriers," she says.

Value: The 2007 Medicare Physician Fee Schedule assigns 1.66 transitional nonfacility total relative value units and 0.75 facility RVUs to 92512. Using a conversion factor of 37.8975, these values equate to $62.91 and $28.42, respectively.