Otolaryngology Coding Alert

Be prepared to fight any denial and support unlisted codes with this key resource.

The American Academy of Otolaryngology — Head and Neck Surgery recently published a Clinical Consensus Statement (CCS) surrounding the use of balloon dilation of the eustachian tube (BDET) for obstructive eustachian tube dysfunction (OETD). This release highlights the importance of CCSs for procedures performed in a clinical setting that must be submitted using an unlisted code or have been denied due to lack of medical necessity.

In addition to BDET for OETD, the AAO-HNS highlights a number of additional CCSs that your practice should become familiar with in the instance that you need further documentation to support a surgical claim.

Have a look at a few important CCSs and how you should incorporate them into your practice.

Begin by Defining Your Terms

First, you’ll want to familiarize yourself with what exactly a CCS is and how you can use it to your advantage.

According to AAO-HNS, “a CCS reflects opinions synthesized from an organized group of experts into a written document. CCSs should reflect the expert views of a panel of individuals who are well-versed on the topic of interest while carefully examining and discussing the scientific data available.” The AAO-HNS includes a caveat that CCSs “are not to be confused with a formal evidence review and are not developed in accordance with Clinical Practice Guidelines (CPGs).”

While CCSs are not CPGs, the development process to produce a CCS is a lengthy and substantial one, as shown in the Clinical Consensus Statement Development Manual. This manual details the eight specific steps involved in developing a CCS, including a planning stage, literature research, and four conference calls.

You can access the list of published AAO-HNS CCSs at  https://www.entnet.org/content/clinical-consensus-statements.

Know How to Use CCSs to Your Advantage

Understanding how you can incorporate a CCS into your coding and billing processes can be tricky. Some CCSs are exclusively designed with the physician in mind. For instance, a CCS titled Appropriate Use of Computed Tomography (CT) for Paranasal Sinus Disease is a helpful reference for providers to review when deciding whether to order a CT scan for patients with paranasal sinus disease.

There are other instances when practice managers and coders can use a CCS to justify medical necessity for a procedure. “I have used the consensus statements as well as the position statements and clinical indicators in appeals — successfully too,” says Jennifer M. Connell, CPC, COC, CENTC, CPCO, CPMA, CPPM, CPC-P, CPB, CPC-I, CEMA, CEMC, owner of E2E Health Solutions in Victoria, Texas.

“They are an invaluable resource to both new and experienced ENT coders. The AAO-HNS is very active in the reimbursement advocacy and do an excellent job reviewing and updating their positions and policies. In my experience, I have only ever seen CCSs used for appeals or to help obtain prior authorization. With that said, I can also see a new ENT physician, either during or fresh out of residency, using the clinical policies to help them with peer-to-peer reviews; or even an experienced ENT physician use CCSs to support testimony as an expert witness,” Connell explains.

Check Out This CCS Example on BDET for OETD

From a practice management perspective, the usefulness of the CCS is best highlighted by the CCS titled Clinical Consensus Statement: Balloon Dilation of the Eustachian Tube. That’s because, as you may already be aware, there are no existing coding options for reporting this procedure. Instead, when your surgeon performs a BDET for OETD, you’ve got to rely on the unlisted code 69799 (Unlisted procedure, middle ear). As coders and practice managers can attest, billing for an unlisted procedure can be difficult without sufficient documentation to address the medical necessity of the procedure.

This is where the CCS comes in handy. By including documentation from the recent CCS as justification for the billing, you are well-equipped to handle any BDET for OETD claims that come your way. In submission of the unlisted procedure claim, you’ll want to highlight any specific points documented in the CCS that directly reinforce your position. For instance, in the Clinical Consensus Statement: Balloon Dilation of the Eustachian Tube, the authors state in the Conclusion section that “this process demonstrated that BDET is an option for treatment of patients with OETD.” To help your cause, you may elaborate in more detail on how the researchers came to the conclusion that BDET is an effective treatment for OETD.

“Unfortunately, the CCS does not include what to equate the unlisted code to, when submitting the unlisted code on a claim,” says Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, AAPC Fellow, of CRN Healthcare in Tinton Falls, New Jersey. “Best practices are to provide the payer with an unlisted code, to guide them in pricing the service,” Cobuzzi advises.

In the case of BDET, Cobuzzi equates the unlisted code 69799 (Unlisted procedure, middle ear) to 31296 (Nasal/sinus endoscopy, surgical; with dilation of frontal sinus ostium (eg, balloon dilation)). BDET for OETD is similar to 31296 in complexity and risk, requiring similar skill levels for the surgeon.

The AAO-HNS’s 12-page Clinical Consensus Statement: Balloon Dilation of the Eustachian Tube can be found for review and download at  https://journals.sagepub.com/doi/full/10.1177/0194599819848423.