Otolaryngology Coding Alert

If you want to stop denials for 30130-30140 performed with 31254-31255, you're going to need to help your payers by providing not only spotless coding and documentation but perhaps some modifiers as well.

To obtain reimbursement for inferior turbinate procedures, you should understand why payment isn't straightforward. Although the National Correct Coding Initiative (NCCI) does not bundle 30130 (Excision turbinate, partial or complete, any method) and 30140 (Submucous resection turbinate, partial or complete, any method) with 31254 (Nasal/sinus endoscopy, surgical; with ethmoidectomy, partial [anterior]) and 31255 ( with ethmoidectomy, total [anterior and posterior]), many insurers deny claims for turbinec-tomies and ethmoidectomies performed together for several reasons, says James N. Palmer, MD, assistant professor in the division of rhinology in the department of otorhi-nolaryngology, head and neck surgery at the University of Pennsylvania in Philadelphia.

For instance, some companies consider middle turbinectomies incidental to ethmoidectomies because the otolaryngologist performs them through the same incision. And insurance companies may deny payment on the basis that the physician excised the turbinate to gain access to the ethmoid.

To further complicate the situation, 30130-30140 do not distinguish between the inferior and middle turbinates. And most insurers bundle middle turbinectomies with ethmoidectomy, thinking the claim is for a middle turbinate excision rather than an inferior turbinectomy, Palmer says. Consequently, operative notes that clearly delineate which turbinate bone the surgeon removed and why are crucial for payment.

To avoid erroneous denials from insurers, make sure the surgical notes fully explain the performed procedures. "The otolaryngologist should dictate a separate paragraph for the turbinectomy and ethmoidectomy," Palmer says. Having the operations individually described will help the payer see that they are indeed separate procedures and should be reimbursed as such, he says.

The physician should describe each procedure in the operative report's body using correct, specific language, says Teresa M. Thompson, BS, CPC, an ENT coding specialist and the owner of TM Consulting, a national medical consulting and management firm in Sequim, Wash. For instance, with turbinate procedures, the otolaryngologist must identify the exact turbinate bone that he or she removes, Thompson says. Failing to identify that the surgeon removed the inferior turbinate will lead the payer to assume that the doctor operated on the middle turbinate bone by default. In this case, the insurer may deny the turbinectomy (30130-30140) as incidental to the ethmoidectomy (31254-31255).

For instance, an operative report that states, "Excised turbinate and anterior ethmoid; removed disease" omits vital information. The coder, as well as the payer, cannot discern which turbinate bone the physician operated on. The insurer will assume that the otolaryngologist excised the middle turbinate and will bundle 30130 with 31254. This error will cost your practice $138.70, based on the Medicare Physician Fee Schedule, which assigns 7.54 relative value units to 30130 and reduces multiple procedures by 50 percent.

Most companies will not reimburse for middle turbinectomies when performed with multiple procedures, Thompson says: "It's usually the inferior turbinates that we try to get reimbursed for."

In contrast, if the surgeon writes "excised inferior turbinate due to turbinate hypertrophy" in one paragraph and "fractured middle turbinate to inspect anterior ethmoid; removed diseased tissue from anterior ethmoid air cells," the payer can clearly see that the otolaryn-gologist performed two distinct procedures. Therefore, the company should pay for both 30130 for the inferior turbinectomy and 31254 for the ethmoidectomy.

Another pitfall occurs if the physician fails to distinguish between turbinate excision and submucous resection. "Pay attention to the way the physician performs the excision or submucous resection," Palmer says.

To perform 30130, the otolaryngologist cuts the bone out, leaving no mucosa and no bone. He preserves nothing and leaves just the stump.

In contrast, 30140 involves removing the turbinate bone through a submucous incision. In this more extensive procedure, the otolaryngologist enters the mucosa, raises the mucoperiosteum flaps, cuts out the turbinate bone and lays the turbinate mucosa flaps back over the turbinate, Palmer says. To bill 30140, you must have documentation in the operative report that the otolaryngologist entered or incised the mucosa and for the most part preserved it.

If the report does not say the surgeon did this, you should report 30130, Thompson says.

You should look for indications that the physician reduced rather than resected the turbinate. "In reduction, the otolaryngologist performs a partial removal of the turbinate without taking the turbinate out," Palmer says. So, you should append modifier -52 (Reduced services) to 30140 to indicate reduction of turbinates, according to CPT's parenthetical note following 30140.

Because modifier -52 requires submitting documentation with the claim, some otolaryngologists prefer not to use 30140-52. The key is whether the documentation says "reduction" or "resection." Use the modifier based on what the surgeon says he or she performed in the operative report.

If your documentation supports an inferior turbinectomy and ethmoidectomy, you have one final tool to use in your battle to show payers that they should not bundle 30130-30140 with 31254-31255. To inform insurers that the physician did not perform the turbinectomy and ethmoidectomy on the same turbinate the middle but on a different bone the inferior turbinate append modifier - 59 (Distinct procedural service) to the turbinate code, coding experts say.

For instance, if your ENT excises the right inferior turbinate and also performs a complete ethmoidectomy on the same side, you should report 31255-RT(Right side) and 30130-59-RT, if documentation supports individual procedures for different reasons. Although payers would normally include the middle turbinectomy in 31255, using modifier -59 indicates that the surgeon performed 30130 on a different site, the inferior turbinate. In this case, modifier -59 should facilitate payment, Thompson says.

Information from Ms. Thompson provided by "Sinus and Turbinate Services Strategies to Optimize Reimbursement" national teleconference. To obtain a transcript, audiotape or compact disk of the teleconference, call The Coding Institute at (800) 508-2582.