Otolaryngology Coding Alert

Multiple sinus endoscopies performed during the same operative session are separately billable, but only if the otolaryngologist clearly describes each procedure in the operative report. Similarly, septoplasty and/or submucous resection of turbinates performed during the same operative session must be carefully described in the procedure notes to increase the chances of separate reimbursement for these services.

To optimize payment, the procedures should be listed in order of value, with the procedure with the most relative value units (RVUs) noted first. But, because many private payers (and reportedly, some local Medicare carriers) are incorrectly denying septoplasty and inferior turbinate resection as incidental to endoscopic sinus surgery, otolaryngologists should be prepared to appeal such denials to the highest level, and should demand medical review of the claim by a board-certified otolaryngologist.

The following operative note, which was requested for review by a private carrier after the HCFA 1500 claim form was received, illustrates how the failure to describe accurately and clearly all procedures performed can result in reduced reimbursement. Otolaryngologists also should remember that inadequately noted, billed procedures may be vulnerable to a future audit.

Operative Report

Preoperative diagnosis: nasal septal obstruction, sinusitis
Postoperative diagnosis: same
Procedures: Septoplasty
Bilateral submucous resection of the inferior turbinates
Bilateral endoscopic sinus surgery with bilateral middle meatal osteoplasties
Bilateral anterior-posterior ethmoidectomies
Bilateral frontal recess approach

Procedure/Findings:
With the patient under satisfactory general endotracheal anesthesia, in the supine position, the nose prepared and draped. A left hemitransfixion incision made. Mucoperichondrial and periosteal flaps elevated bilaterally. A good anterior-superior strut of cartilaginous septum was left intact. Badly deviated portions of bone and cartilaginous septum were removed to bring the septum to the midline. Flaps were replaced and sutured.

The left uncinate was infiltrated under 0-degree telescopic guidance. Infundibulotomy performed, sectioning the uncinate with a sickle knife, and removing with a Blakesley forceps. The ostium of the maxillary sinus was located and middle meatal osteoplasty performed with curet and backbiting forceps.

The ethmoids were entered through the bulla ethmoidalis and anterior ethmoidectomy performed, removing polyps throughout. A 30-degree scope was brought into place and the final recess opened with upbiting Blakesley forceps. The posterior ethmoids were entered through the ground lamella, the middle turbinate and the posterior ethmoidectomy performed. The middle meatus filled with Bactroban and Gelfoam.

Attention was turned to the right side of the nose, where an identical anterior-posterior ethmoidectomy, frontal recess approach and middle meatal osteoplasty were performed.

Both inferior turbinates were upfractured, mucous membrane incised, medial and lateral flaps developed. A portion of inferior turbinal bone removed, flaps trimmed and sutured, and the nose packed with rolled Telfa.

Coding the Session

The otolaryngologist billed a private carrier and listed the following procedures in the following order:

31276 nasal/sinus endoscopy, surgical with frontal sinus exploration, with or without removal of tissue from frontal sinus (15.11 RVUs);

31276-50 bilateral procedure (7.555 RVUs);

31255 nasal/sinus endoscopy, surgical; with ethmoidectomy, total (anterior and posterior) (12.54 RVUs);

31255-50 bilateral procedure (6.27 RVUs);

31256 nasal/sinus endoscopy, surgical, with maxillary antrostomy (5.97 RVUs);

31256-50 bilateral procedure (2.985 RVUs);

30520 septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft (12.09 RVUs);

30140 submucous resection turbinate, partial or complete, any method; (7.81 RVUs); and

30140-50 bilateral procedure (3.905 RVUs).

Three diagnosis codes were included in the claim: 473.8 (pansinusitis, chronic) was linked to the three bilateral sinus procedures, 470 (deviated septum) was linked to the septoplasty, and 478.0 (hypertrophy of nasal turbinates) was associated with the submucous resection of inferior turbinates.

Missing Frontal Sinus Endoscopy

Based on the information contained in this operative report, the highest-paying procedure the frontal sinus endoscopy could not be billed, because it is not documented. Therefore, bilateral frontal sinus endoscopy should not have been billed, says Stella Almassian, administrator of the department of otolaryngology at Northwestern University in Chicago. The otolaryngologist briefly mentions a frontal recess approach but makes no mention at all about exploring the frontal sinus. She adds that the frontal recess approach could also be used to perform the posterior ethmoidectomy.

According to Lee Eisenberg, MD, an otolaryngologist in Englewood, N.J., and a member of CPTs editorial panel and executive committee, a procedure note describing a frontal sinus endoscopy should mention the exploration of the nasofrontal duct.

Given the diagnosis of pansinusitis, its entirely possible the otolaryngologist did in fact perform the bilateral frontal endoscopy he claimed, Eisenberg says. However, briefly mentioning a frontal recess approach is not the same thing as describing a frontal sinus exploration. There is nothing to indicate the frontal sinus area was entered. There is no duct exploration, therefore this procedure should not be billed, either bilaterally or unilaterally.

The other claimed procedures are sufficiently described in the operative report to warrant payment. Of particular note is the description of the submucous resection of inferior turbinates, which clearly differentiates what was performed from a turbinate excision (30130) by noting the incision of the mucous membrane and the development of medial and lateral flaps, Eisenberg says.

The report shows that the otolaryngologist elevated the mucosa, collapsed the turbinate bone and took out the bone, and sutured flaps back together. That makes it a submucous resection.

Note: Otolaryngologists should specifically note that the inferior not the middle turbinates, were resected, because any work on the middle turbinates is considered incidental to endoscopic sinus surgery.

Special Instructions When Billing Private Payers

Private carriers often process claims differently than Medicare carriers. Medicare carriers automatically order claims involving more than one procedure from highest value to lowest. Although many private carriers also use software that does the same thing, others do not. Therefore, when submitting such claims to third-party payers, otolaryngologists should list the procedures from highest to lowest value. If the otolaryngologist does not do so, the carrier may select a lesser-valued procedure for 100 percent payment and pay the others (including the highest paying procedure) at a reduced rate as multiple procedures.

In this case, the frontal sinus exploration was listed first, which would have been correct had the procedure been payable. As mentioned previously, however, this bilateral procedure should not have been billed at all. Instead, the first procedure listed should have been 31255, followed by 30520, 30140 and 31256. When ordering the procedures, its important to remember to value procedures performed on both sides at 150 percent (unless the code already includes a bilateral component, which is not the case with the three bilateral procedures performed during this operative session).

Note also that Medicare carriers require bilateral procedures to be billed on one line, as follows:

31255-50

However, many private payers still require a two-line entry for bilateral procedures, as was correctly done in this claim, as follows:

31255
31255-50

Note: On a two-line entry, the value of the bilateral procedure is totaled and both lines precede any subsequent procedures (bilateral or unilateral) with fewer RVUs.

In short, the claim should have been submitted to the private carrier as follows:

31255
31255-50
30520
30140
30140-50
31256
31256-50

Note: When billing private payers, it may also be helpful to attach modifier -51 (multiple procedures) to all procedures other than the first. Although the utility of this modifier is questioned by a growing number of payers, physicians and coding specialists, it can still be useful by identifying all procedures other than the highest-valued procedure, and therefore ensuring the correct (highest-valued) procedure is paid at 100 percent.

Because many private carriers inappropriately bundle septoplasties to endoscopic sinus procedures and turbinate resections to septoplasties and sinus endoscopies, the turbinate work and/or the septoplasty may be denied. Such denials should be vigorously appealed, and supporting documentation from the American Academy of Otolaryngology and the American Medical Association should be cited to support such appeals. Also note that septoplasties and turbinate resections are not bundled to each other or to any sinus endoscopies in the CCI.