Otolaryngology Coding Alert

Otolaryngologists could be walking the envelope of fraud in using open sinusotomy codes (31090, sinusotomy, unilateral, three or more paranasal sinuses [frontal, maxillary, ethmoid, sphenoid]) for endoscopic sinus procedures, coding experts warn.

Open codes dont accurately reflect the procedure, and they pay out below the multiple endoscopic sinus theyre often used to replace. The coding shortcut also can close the door to reimbursements for the post-op procedures for 90 days, says Barbara Cobuzzi, MBA, CPC, CHBME, president of Cash Flow Solutions, a physician reimbursement consulting firm in Lakewood, NJ.

Consequences High

The risks of an audit and even accusations of fraud are high. Coding guidelines clearly indicate physicians must use the codes that most accurately describe a procedure. The physician who bills for an open procedure runs the risk that the operative report will disclose the procedure as endoscopic.

The federal penalty for fraudulent Medicare billing can total as much as three times the amount billed, plus thousands of dollars more in damages per incident.

Take, for example, the case of a patient with chronic sinus headache and intermittent green drainage from his nose. His internist has frequently prescribed antibiotics, but now, frustrated by the lack of improvement, sends his patient to the otolaryngologist, who orders a CT scan of the sinus, which shows chronic disease of the ethmoid, sphenoid and maxillary sinuses. In addition, the patient also has a mucocele in the maxillary sinus. The sinus disease and the mucocele are bilateral. So the patient is scheduled for bilateral total endoscopic ethmoidectomies, bilateral sphenoidotomies and bilateral endoscopic maxillary antrostomies with removal of mucocele.

To correctly bill the procedures just described, the coding should be as follows, says Kim Pollock, RN, MBA, an otolaryngology coding and reimbursement specialist in Dallas, TX:

31255: nasal/sinus endoscopy, surgical; with
ethmoidectomy, total [anterior and posterior];

31255-50: bilateral procedure

31267-51: nasal/sinus endoscopy, surgical, with removal of tissue from maxillary sinus

31267-50-51: bilateral procedure

31287-51: nasal/sinus endoscopy, surgical, with sphenoidotomy

31287-50-51: bilateral procedure.

The total number of RVUs billed is 70.28. If the patient is covered by Medicare, the otolaryngologist can expect to be paid for 42.77 RVUs. However, if the otolaryngologist billed the entire procedure with the open 31090 code, the most he could expect from a reimbursement standpoint is 32.81 RVUs.

Clearly, billing 31090 in place of multiple endoscopic sinus procedures is risky and a poor reimbursement strategy. So why would any otolaryngologist use this approach? Coding and reimbursement specialists say that some physicians are taking this drastic step out of frustration with the reimbursement policies of some private payers.

For example, many health insurance carriers now try to bundle maxillary and sphenoid endoscopies to the ethmoid procedure, Cobuzzi says. Others pay 50 percent of an already low fee schedule for second surgeries, and then 25 percent on third, fourth and fifth procedures. Often, when inferior turbinates are excised or reduced, that procedure is automatically (and incorrectly)
bundled as well.

In those circumstances, reimbursement may very well be higher for code 31090. And some otolaryngologists can rationalize their use of it by arguing that they are, in fact, performing surgery on three or more sinuses.

Meanwhile, Pollock notes that the open sinus procedure is performed infrequently because the standard of care has changed and most otolaryngologists now perform the procedure endoscopically, emphasizing that repeated use of the code is a red flag for auditors.

Note: If some carriers are instructing their providers to bill the procedures this way, they must get that instruction in writing to avoid legal complications.

Appeal and Precertify

Otolaryngologists have resources to obtain appropriate reimbursement for these procedures.

The first weapon in their arsenal is precertification. Often, an otolaryngologist will get precertification for one procedure but during the course of surgery perform another or additional procedures. For example, the physician may give a patient with sinus disease a diagnostic scope as well as a CT scan, and on the basis of the results of those tests, get precertification for functional endoscopic sinus surgery (FESS). This could mean an ethmoidectomy, or it could be for maxillary tissue removal, but in most circumstances, no more than that. However, once in the OR suite, the otolaryngologist may determine that much more needs to be done, which could include sphenoid work or any number of other procedures. Once the procedures are over, the physician will return to his or her office and not mention the extra work to his staff.

The next week, the office staff receives the operative report, which lists all the procedures the otolaryngologist performed, including those that werent precertified. All the procedures are then listed on the claim form, but the insurance company pays only for the ethmoidectomy. When an appeal is filed, the insurance company says that precertification for the other procedures was not obtained. Even though the otolaryngologist explains to the payer that there was no way to know what he or she would find, Cobuzzi says, some carriers use the lack of precertification as a reason not to pay.

To minimize such occurrences, Cobuzzi advises physicians who perform more extensive surgery than expected to inform their staff what they did as soon as they return to the office. By doing so, the office can amend the precertification to reflect what was done and get it documented in the payers records. This gives the otolaryngologist more ammunition if an appeal needs to be filed. If billing claims are rejected because the carrier is bundling inappropriately, the otolaryngologist should appeal.

Of course, not all carriers have the same reimbursement policies. With more problematic payers, says Pollock, you should get written pre-authorization letters. Pollock also suggests that otolaryngologists check the payers bundling rules before signing a managed-care contract, because some contracts state that the carrier reserves the right to bundle any procedure into the primary procedure, Pollock says.

Capitalize on Zero Global Days

Some otolaryngologists may suffer from appeal fatigue and believe they will get paid more quickly and at a higher rate by charging the 31090, even if it isnt the most accurate description of the procedures they performed. But making a false claim is a serious issue. It also bears repeating that by not billing correctly, practices are losing potential reimbursement opportunities in the post-op period.

They lose because 31090, the incisional procedure they are reporting, has a 90-day global period, which means that any and every post-op visit with the patient after the procedure for 90 days is bundled into the original procedure. On the other hand, endoscopic sinus surgery without a septoplasty has 0 global days.

Note: Some insurance carriers attach a 90-day global period to endoscopic sinus procedures.

For example, often when an otolaryngologist performs endoscopic surgery, the patients nose is packed with gauze. The next day, all the packing is removed. Subsequently, debridement may be performed, and further diagnostic scoping (31237, nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement [separate procedure]). If the original procedure was endoscopic, each of those visits is billable.

Unfortunately, many otolaryngologists dont bill for these post-op visits even though they can, Cobuzzi says. In the old days, when otolaryngologists received $3,500 for an ethmoidectomy, they didnt worry about billing for the next day, she says, adding that the fees can be from $60 (no debridement) to $200 (debridement). But now they make one-quarter that amount, so all the visits after, of which there are several, are chargeable and worth billing.

These strategies may not entirely eliminate the otolaryngologists frustration with how multiple endoscopic sinus procedures are paid. But using them will ensure more reimbursement and avoid legal entanglements that could be even more frustrating and more costly.