Otolaryngology Coding Alert

Hint: Knowing what not to code is half the battle.

You may come across the use of acellular hydrated dermal tissue such as BellaDerm^® during a wide variety of ENT reconstruction and revision surgeries. However, there’s a great deal of confusion surrounding how you should code this connective tissue allograft when placed underneath the dermal layer in the nose for reinforcement purposes.

If uncertainty and denials are making you reluctant to code these cases, read on. Use the following case scenario to better understand the considerations when reporting the use of BellaDerm^® in ENT cases and gain confidence in overcoming this coding conundrum and submitting clean claims every time.

Read the Case

The patient is a 33-year-old female with a history of severe nasal injury as a child. Since the injury, she has had bilateral nasal obstruction L>R. She complains of chronic mouth breathing and snoring. The patient has failed medical nasal treatments including antihistamines and intranasal steroids. She has noted functional limitations, with difficulty with exertional activities and sleeping at night. On exam, there is evidence of severe left septal deviation, nasal valve collapse, nasal bone deviation, as well as tip ptosis with lack of tip support.

Surgical treatment included:

• Complex functional open septorhinoplasty
• Inferior turbinate outfracture
• Lateral nasal wall reconstruction with repair of vestibular stenosis via bilateral spreader grafts and alar strut graft
• Septal cartilage grafting to external nose
• Support of soft tissue atrophy with reinforcement of thin nasal skin and thin mucosal flaps with BellaDerm^® allograft

In this case, the patient had extremely twisted, thin, irregular, and asymmetrical nasal tip cartilage that didn’t provide much support. During the septorhinoplasty and wall reconstruction, the otolaryngologist used BellaDerm^® sheets to reinforce the grafts.

Peruse the Problem

Reporting the procedures might initially seem straightforward. Proper coding would include the following:

• 30420 (Rhinoplasty, primary; including major septal repair)
• 20912 (Cartilage graft; nasal septum)
• 30930 (Fracture nasal inferior turbinate(s), therapeutic)

But uncertainty arises when trying to decide how to code the BellaDerm^® allograft.

Initially, you might think using +15777 (Implantation of biologic implant (eg, acellular dermal matrix) for soft tissue reinforcement (ie, breast, trunk) (List separately in addition to code for primary procedure)) seems reasonable because, at first glance, it meets the surgical criteria of what you’re looking for. But the anatomic sites don’t align.

Your next instinct may then be to instead report unlisted code 17999 (Unlisted procedure, skin, mucous membrane and subcutaneous tissue) and use code +15777 as a reference code for reimbursement purposes, making sure you submit the claim on paper with the appropriate documentation.

This notion is supported by two different sources:

• An article published in April 2021 by the American Academy of Otolaryngology – Head and Neck Surgery (AAO-HNS) recommends using 17999 for these types of cases. “Providers implanting biologic implants for soft tissue reinforcement in areas such as the head or neck (such as implantation of Alloderm^® into a parotidectomy wound bed) are now instructed to use the unlisted code CPT 17999 to report these procedures.”
• Likewise, the Essential Guide to Coding in Otolaryngology, 2nd edition says under allografts, “Currently there is not a code for placement of acellular dermis as soft tissue reinforcement in the head and neck. Add-on code, 15777, is reported only when placed in the breast or trunk, not head and neck. Use an unlisted code, such as 17999 and compare to 15777 for a head and/ or neck procedure if the biologic tissue is placed below the skin for soft tissue reinforcement.”

But further research suggests this is not the code you’re looking for.

CPT^® Assistant Throws a Wrench in the Plan

Code 17999 initially seems like a great solution until you come across the February 2022 CPT^® Assistant (volume 32, issue 2), published after the above two guidance resources were published. It states that the reporting rules for +15777 — which should only be reported in conjunction with codes for integumentary system procedures — also apply to the unlisted procedure 17999 when the biologic implant is being used in an anatomic area other than the breast and trunk. In other words, “17999 replacing add-on procedure +15777 may only be reported in conjunction with base codes for procedures in other than breast or trunk anatomy that are in the Integumentary System section,” says Barbara J. Cobuzzi, MBA, CPC, COC, CPCO, CPC-P, CPC-I, CENTC, CMCS, of CRN Healthcare Solutions in Tinton Falls, New Jersey.

Since 30420, 20912, and 30930 are not procedure codes in the Integumentary System section of CPT^®, “17999 cannot be used even though it seems to be the best code to describe what was done given all the history of the codes and instructions up until February 2022 when CPT^® Assistant published this guidance,” Cobuzzi adds.

Put Your Thinking Cap On

Since the BellaDerm^® allograft is reinforcing the nasal septal graft and reconstruction, one option is to append modifier 22 (Increased procedural services) to the septorhinoplasty primary code to cover the additional work, making sure to include thorough documentation detailing the increased intensity, time, technical difficulty of the procedure, and/or physical and mental effort required. But the appropriateness of this option will depend on the documentation and additional work involved.

Alternatively, since the doctor is reinforcing tissue in the nasal area, you could use 30999 (Unlisted procedure, nose). Submitting an existing reference code alongside an unlisted code is important for contextual purposes, so equate it to +15777 to aid in valuing the unlisted code. This is the preferred reporting option because if or when a new code is created for the use of allograft tissue as reinforcement in ENT procedures, the unlisted code submissions will help the Centers for Medicare & Medicaid Services (CMS) determine the new code’s relative value units (RVUs) by providing a reasonable comparison, according to Cobuzzi.