Otolaryngology Coding Alert

You don't have to be a super sleuth to unravel functional endoscopic sinus surgery (FESS) operative reports if you employ these insider tactics.

For optimal ENT coding, you-ve got to understand anatomic landmarks that the otolaryngologist might cite to know where in the sinuses the surgeon is working, says Joanne Schade-Boyce, RDH, MS, CPC, ASC, PCS, in AudioEducator.com's "Anatomy and Coding Essentials for Optimal FESS Reimbursement." The surgeon might note a landmark to indicate he's going into another sinus, Boyce points out. To capture codeable procedures, try these best practices.

If your otolaryngologists are accessible to you, arm yourself with your notes, coding book and anatomy book, and ask them to talk to you about the procedures they commonly perform, suggests Schade-Boyce. "Have them walk you through how they dictate to see if there are opportunities for additional reimbursement."

Heads up: Did the surgeon go through the anterior ethmoid? If he came into this sinus for medically necessary reasons, then you should bill for the ethmoidectomy (31254, Nasal/sinus endoscopy, surgical; with ethmoidectomy, partial [anterior]), Schade-Boyce says.

Beware: If you spot sphenoid (31287, Nasal/sinus endoscopy, surgical, with spehnoidectomy; 31288, - with removal of tissue from sphenoid sinus; and/or 31291, Nasal/sinus endoscopy, surgical, with repair of cerebrospinal fluid leak; sphenoid region) in the operative report, ask the otolaryngologist how he got there. An ethmoidectomy could be billable if it was medically necessary. But if the surgeon used the sinus as the "freeway on the way to the sphenoids," it is not a billable service.

When you see "stenosis -- nasal valve" in an operative report, a light should go off in your head. You should think, "I wonder if the surgeon did 30465," (Repair of nasal vestibular stenosis [e.g., spreader grafting, lateral nasal wall reconstruction]) Schade-Boyce says.

If a patient's nasal valve angle has narrowed (stenosis) to less than 10- to 15-, he may not breathe right. Code 30465 describes the techniques the surgeon might use, such as spreader grafting or lateral nasal wall reconstruction, says Amit Joshi, MSc, senior medical coder for Prexis Health India Ltd. in Pace City II, Gurgaon, India. "Osteotomy [cutting for realignment] of nasal bones is a buzz word in these types of cases."

In nasal valve repair, the ENT may create a graft that he puts up into the patient's nose, like shocks lifting up a car, to open up the angle. "For instance, harvested nasal cartilage [from the patient's nasal septum] is often used as a spreader graft or as a nasal alar batten graft to repair a dysfunctional or collapsed internal nasal valve," according to Coders- Desk Reference. In this case, you should separately use 20912 (Cartilage graft; nasal septum), Joshi says.

Don't miss: You need to use modifier 52 (Reduced services) on 30465 if a surgeon does not perform the repair bilaterally, Schade-Boyce says.

If you have never seen concha bullosa in an operative report, talk to your doctors. "They may not dictate endoscopic concha bullosa resection (31240, Nasal/sinus endoscopy, surgical; with concha bullosa resection) because they don't know it's separately reportable," Schade-Boyce says. Or, they may not dictate it because they do not remove it endoscopically. It is always good to make sure.

There's no reimbursement for middle turbinates. Therefore, when the surgeon drops down there to remove a concha that impinges on the septum, he may similarly think the procedure is nonreportable.

You do not want to miss out on those dollars, Schade-Boyce says. Read the operative report, not just the procedures list, or you could miss out on concha bullosa resection descriptions that could cut approximately $166 from a bilateral 31240 with a multiple procedures claim, using the 2008 Medicare Physician Fee Schedule. Code 31240 contains 4.35 RVUs (x 38.0870 2008 conversion factor x 100 percent (150 percent bilateral pay " 50 percent multiple procedure reduction) = $165.68 for bilateral 31240 with a FESS).

On multiple procedures claims, get in the habit of reporting procedures from highest to lowest valued. Although Medicare automatically places procedures in descending order to apply multiple procedures- payment reduction, other payers- systems are not as savvy.

Third-party payers may apply reductions using the order you provide on the claim form, Schade-Boyce says. You may need to reorder claims involving bilateral procedures.

Why: A lower-paying bilateral procedure might trump a higher-paying procedure. For instance, if an otolaryngologist performs unilateral FESS (31254-31288) with septoplasty (30520, Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft), the septoplasty is higher (14.67 RVUs), Schade-Boyce notes. But if the surgeon performs bilateral FESS, that procedure is valued higher than the septoplasty.

Tip: "If you-ve been using modifier 50 (Bilateral procedure), look at your payments to see if the insurer has been paying you unilaterally (at 100 percent) instead of bilaterally (at 150 percent)," says Schade-Boyce. Audits frequently reveal documentation and coding that supports a bilateral procedure that the insurer has paid unilaterally.

The insurer may incorrectly process Medicare's preferred modifier 50 method of a one-line entry with modifier 50 (such as 31254-50). Private payers may want bilateral procedures on either two lines with modifier 50 on the second line (31254, 31254-50) or no modifier with two units on a single line item (31254 x 2).

Finally, be skeptical when you have chronic sinusitis unspecified (473.9) as the only operative report ICD-9 code. If the patient's sinus condition is at the point where he requires FESS, the diagnosis should really be specific, Schade-Boyce says.

Do this: Look in the operative report findings to get precise details about the real problem, such as removal of antral disease. Use the specific diagnosis that indicates the need for each sinus procedure. For instance, support maxillary antrostomy (31256, Nasal/sinus endoscopy, surgical, with maxillary antrostomy) with chronic maxillary sinusitis (473.0) and total ethmoidectomy (31255, Nasal/sinus endoscopy, surgical; with ethmoidectomy, total [anterior and posterior]) with chronic ethmoid sinusitis (473.2), provided documentation includes these diagnoses.

If the physician does not include the diagnoses in the operative note, talk to her about documenting them. Explain to her that just documenting chronic sinusitis or pansinusitis is not sufficient for billing and reimbursement.