Otolaryngology Coding Alert

Find out why you should avoid coding a septoplasty in the presence of 21330.

When you're face-to-face with a transnasal turbinate surgery claim, make sure to put your clinical judgment call on high alert given the variety of anatomic sites, surgical techniques, and types of instrumentation involved in this type of service.

Example: Your otolaryngologist removes the middle turbinate during an endoscopic ethmoidectomy (31254, Nasal/sinus endoscopy, surgical; with ethmoidectomy, partial [anterior], or 31255, Nasal/sinus endoscopy, surgical; with ethmoidectomy, total [anterior and posterior]) or endoscopic polypectomy (31237, Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement [separate procedure]). The middle turbinates are considered access to the sinuses, so you should be able to tell that the removal of the middle turbinate should not be reported separately.

Check out these 3 frequently asked questions (FAQs) to help master your turbinate surgery coding skills.

Should 30130 and 30140 Go Hand-in-Hand?

Suppose the documentation states that the physician entered or excised mucosa and subsequently preserved it. This implies that you should use 30140 (Submucous resection inferior turbinate, partial or complete, any method) to report this service. However, simply reporting that the turbinate was excised is probably not enough documentation for this code. Don't forget to bill 30130 (Excision inferior turbinate, partial or complete, any method) if there is no evidence of the preservation of the mucosa and the op note just indicates that the inferior turbinate was excised or resected.

Remember that you should not bill 30140 with 30130 -- you would bill one or the other, for a single side. "However, if a submucousal resection (preservation of the mucosa) is performed on one side and a straight excision is performed on the other side (no preservation of mucosa), you would code 30140-RT and 30130-59-LT, for example," explains Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J. The RT and LT would represent which side each procedure was performed, she adds.

Quick facts: You would usually report 30130 or 30140 separately with septoplasty (30520, Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft, or 30620, Septal or other intranasal dermatoplasty [does not include obtaining graft]) or a functional endoscopic sinus surgery (31254-31299) is performed along with an inferior turbinate removal, either excision (30130) or submucous resection (30140), preserving the mucosa.

CPT 31240 (Nasal/sinus endoscopy, surgical; with concha bullosa resection) describes the removal of a middle turbinate endoscopically. You would code this when the concha bullosa is removed during endoscopic sinus surgery. CPTs 30130 and 30140 should not be used if the turbinates excised non-endoscopically were middle turbinates. If the physician removed the middle turbinates via excision or resection (not endoscopically), as in a middle turbinectomy and septoplasty, you would use the unlisted nasal code for the middle turbinectomy, 30999 (Unlisted procedure, nose)

Key: You should always consider 30130 and 30140, along with 30930 (Fracture nasal inferior turbinate[s], therapeutic) and 31240 (Nasal/sinus endoscopy, surgical; with concha bullosa resection), as unilateral codes. This means that you add the modifier 50 (Bilateral procedure) if the physician performed the procedure bilaterally. CPT 30140 is "modifier 50-allowed," says Candice Ruffing, CPC, CENTC, 2009-2010 Secretary Local Sailfish Chapter, South Coast Ear, Nose and Throat in Port St Lucie, Florida.

How Much Can We Get From Uni Turbinate Claims?

You should note the different relative value units (RVUs) that unilateral turbinate codes carry so you can have an idea on how much you would be paid. For example:

• 30930 has 3.61 RVUs ($122.65 profit if multiplied by 2011 conversion factor of 33.9764);
• 30130 has 11.08 RVUs ($376.46 profit if multiplied by 2011 conversion factor of 33.9764);
• 30140 has 12.77 RVUs ($433.88 profit if multiplied by 2011 conversion factor of 33.9764); and
• 31240 has 4.83 RVUs ($164.11 profit if multiplied by 2011 conversion factor of 33.9764).

Keep in mind that when the turbinate procedure is part of a multiple procedure surgery, it will be divided in half when adjusted for the multiple-surgery reimbursement.

Consider this example: An otolaryngologist performs a septoplasty, submucous resection of inferior turbinates, and open reduction and internal fixation of nasal fracture. The surgeon states that he performed septoplasty for the cartilage. The nasal fracture reduction and fixation treated the severe deformity and the inability to breathe. How should I code this? How much profit should I expect?

Code it: You should report two of the three surgeries: the turbinate resection (30140) and the fracture treatment (21330, Open treatment of nasal fracture; complicated, with internal and/or external skeletal fixation). Do not bill the septoplasty (30520) since CCI Edits bundles it with 21330. You should get about $786 as total reimbursement for both procedures ($216.94 [$433.88 times 50 percent] as a secondary procedure for 30140 plus $568.76 for 21330 [16.74 RVUs multiplied by2011 conversion factor of 33.9764]).

Note: Multiple procedures (i.e., 30140) are paid at 50 percent of the fee schedule.

Does Inferior and Middle Turbinates Refer To The Same Thing?

When you bill 30130 or 30140 (inferior turbinates), the payer should not confuse your billing for it with the middle turbinates. Since 2006, 30130's definition has been changed from "any turbinate" to "inferior turbinate." "This was done because so many payers denied 30130 and 30140 when coded for inferior turbinates and endoscopic sinus surgeries assuming that the resection was performed on the middle turbinates which are considered access to the sinuses. By changing the wording and definition of the codes, there can be no question by the payer as to whether the procedure was performed on the inferior turbinates," says Cobuzzi.

Still puzzled? Remember, there are three nasal turbinates inside each of the nasal cavity: inferior, middle and superior. The function of nasal turbinates is to regulate the flow of the air through the nose and to trap inhaled particles that may be harmful to the lower respiratory mucosa. Additionally, they humidify and warm the air so that when it reaches the lungs it would be saturated with moisture and equal to the body temperature.

In summary, middle turbinate removal is considered incidental to endoscopic sinus surgery unless the middle turbinate was a concha bullosa which was removed endoscopically, (31240). Inferior turbinectomies are not considered incidental or bundled with endoscopic sinus surgery, septum surgery or other nasal surgery and may be billed separately. But only one turbinate procedure per side may be billed per operative session.