Otolaryngology Coding Alert

The latest version of the national Correct Coding Initiative (CCI), version 6.2 of the Healthcare Financing Administrations (HCFA) Correct Coding Manual, bundles code 61795 (stereotactic computer assisted volumetric [navigational] procedure, intracranial, extracranial, or spinal [list separately in addition to code for primary procedure]) to most, but not all, endoscopic sinus surgeries, as well as to turbinate resection (30140), fracture (30930), and septoplasty (30520).

At the time of writing, HCFA has yet to announce an effective date for implementation of version 6.2. The edits to 61795 are a serious reimbursement change, otolaryngology coding experts contend. Otolaryngologists who use InstaTrak the brand name for the stereotactic image guidance system when performing the procedures to which 61795 will be bundled, find their billing choices limited.

InstaTrak uses an electromagnetic tracking system that builds a computerized model of the patients skull anatomy with CT scans prior to surgery. During the surgery, the patient is fitted with a headset that aligns the images taken by the endoscope with the presurgical model of the patients anatomy. This allows the otolaryngologist to see around corners and better locate surgical instruments in relation to the patients surrounding anatomy tasks that cannot be performed using the endoscope alone.

The increasing use of this system is a prime reason for the bundling of 61795. Another reason is the codes descriptor, which more appropriately defines stereotactic image guidance during deep brain procedures and other services more complicated than its use in sinus surgery.

Because the procedure was valued with more complicated services in mind, and because more and more physicians claim for the service, the CCI edit does not come as a complete surprise, says Lee Eisenberg, MD, an otolaryngologist and member of CPTs editorial panel and executive committee.

Since the use of InstaTrak has become routine for many otolaryngologists, Medicare (and private) carriers may view the service as an integral part of the primary procedure performed, Eisenberg speculates, and may have determined that the increasing number of claims (at a payment amount originally meant for deep brain surgery) constitutes abuse.

Code 61795 was valued so high, much like code 69990 (use of operating microscope [list separately in addition to code for primary procedure]), that these codes sometimes paid more than the primary services they were being used for, Eisenberg says, adding that carriers often deny payment for add-on codes because they cannot be deemed as multiple procedures and therefore they cannot reduce the fee.

Note: According to the 2000 National Physician Fee Schedule Relative Value Guide, 61795 was assigned 8.98 RVUs, whereas, for example, 31254 (nasal/sinus endoscopy, surgical; with ethmoidectomy, partial [anterior]) was valued at 7.71 RVUs.

On the other hand, he also notes that the use of InstaTrak takes more of the otolaryngologists time and effort, but the codes to which 61795 will be bundled have not been revalued to take the extra work into account.

Still, Eisenberg points out, once version 6.2 takes effect, the service will not be billable and otolaryngologists will receive no additional reimbursement for performing the additional service, even in technically difficult cases where it is used appropriately.

A committee of the American Academy of Otolaryngology already has taken up the issue, says Eileen Giaimo, the academys assistant director of socio-economic affairs. Changes to the reimbursement status of this procedure may be forthcoming in subsequent editions of the CCI, Giamo says, noting that although the American Academy of OtolaryngologistsHead and Neck Surgeons (AAO-HNS) was consulted before the changes to version 6.1 were published, no consultation took place for version 6.2. The academy has had input into version 6.3, however, she notes.

Solutions could include either a new stereotactic CPT code designed specifically for InstaTrak use during endoscopic surgery, or alternatively, increasing the value of existing endoscopic codes to reflect routine InstaTrak use.

Modifiers Wont Override Edit

Code 61795 has been bundled to the following codes:

30140 submucous resection turbinate, partial or
complete, any method

30520 septoplasty or submucous resection, with or
without cartilage scoring,contouring or
replacement of graft

30930 fracture nasal turbinate[s], therapeutic

31254 nasal/sinus endoscopy, surgical; with
ethmoidectomy, partial (anterior)

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

31256 nasal/sinus endoscopy, surgical; with
maxillary antrostomy

31267 nasal/sinus endoscopy, surgical; with
maxillary antrostomy, with removal of tissue
from maxillary sinus

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

A 0 indicator is included in all these edits, which means that no modifiers, including modifier -59 (distinct procedural service) may be used to override the bundle.

Interestingly, codes 31287 (nasal/sinus endoscopy, surgical, with sphenoidotomy) and 31288 (nasal/sinus endoscopy, surgical, with sphenoidotomy; with removal of tissue from the sphenoid sinus) still dont include 61795 as a component code, so use of the InstaTrak for these two sphenoid sinus procedures still may be payable, says Cheryl Odquist, CPC, an otolaryngology coding and reimbursement specialist in San Diego.

As there does not appear to be a clinical reason for distinguishing between the sphenoid and the other sinuses in terms of InstaTrak use, it is likely that the omission of 31287 and 31288 was simply an oversight that may be corrected in subsequent versions of the CCI. It also is likely that the entire issue will be reconsidered once the AAO-HNS offers its opinion for version 6.3.

Although HCFA has announced that the effective date for the implementation of version 6.2 has been postponed, the agency recommends that providers code according to the edits in the manual in the interest of correct coding. The National Technical Information Service (NTIS) Web site (www.ntis.gov/cci) instructs providers filing claims for services performed between July 1 and Sept. 30, 2000, to follow the edits in version 6.2.

Use Modifier -22 for Complications

Even so, otolaryngologists still may be able to receive some payment for InstaTrak use in very complicated cases by attaching modifier -22 (unusual procedural services) to the primary procedure. The amount of extra time, however, would have to be significant (probably more than 30 minutes) and the documentation, which must accompany such claims, must be accurate and thorough to clearly indicate to the carrier why additional reimbursement is being sought.