Otolaryngology Coding Alert

It pays for otolaryngologists to have a strategy in place when commercial carriers reject services provided after fiberoptic endoscopic sinus surgery (FESS) procedures. Carriers are denying payment for postoperative service, citing it is part of the FESS global period, even though Medicare has assigned such procedures 0 global days.
Although such denials have been called inappropriate and unreasonable by concerned physician groups, such as the American Academy of Otolaryngologists-Head and Neck Surgeons (AAO-HNS) and the American Rhinologic Society (ARS), select payers still assign a 90-day global period to FESS procedures. Otolaryngology coders should be prepared to deal with such situations if and when they arise.

Some commercial carriers will not pay for post-op care on FESS procedures such as debridement because they assign a global period to the endoscopic sinus procedure, says Barbara Cobuzzi, MBA, CPC, CPC-H, a coding and reimbursement specialist in Lakewood, N.J., who was named 1999 Networker of the Year at the American Academy of Professional Coders annual conference in Minneapolis in May. And when they deny the service, they are in effect implying that charging for postoperative care constitutes unbundling and inappropriate coding.

For example, Cobuzzi notes, an otolaryngologist who performs a bilateral total ethmoidectomy (31255-50) as well as a maxillary antrostomy on the left side (31267-LT), with 0 global days according to Medicare, sees the patient 15 days after surgery for an exam and a debridement. Both services are denied because the commercial insurance carrier has assigned a 90-day global period to the FESS procedure.

The arguments carriers use to justify changing the global period from 0 days to 90 days include:
Services such as postoperative endoscopy and debridement, not to mention visits, amount to little more than a postoperative checkup.
CPT surgery guidelines state that listed surgical procedures include the operation per se ... and normal uncomplicated follow-up care.
Some carriers have used otolaryngology consultants who agree that FESS procedures should have a 90-day global period.

These arguments are vigorously opposed by otolaryngologists and their professional associations, who note three main concerns:
1. CPT guidelines take no position on the length of global packages for individual procedures, and services with 0 global days assigned by Medicare include only normal, uncomplicated follow-up care provided the same day as FESS. Any service provided after the day of surgery is supposed to be paid separately.
2. Postoperative endoscopy and debridement are not checks of past work, they are medically necessary, planned services.
3. Consultants without specific FESS training may be comparing these procedures to older, open sinus procedures that do have a 90-day global period. Such open procedures however, have little in common with FESS, and Laura E. Loeb, J.D., legal counsel for AAO-HNS and ARS, recommends that any physician providing advice to payers on FESS procedures should have performed these procedures, and payers should make public the consultants experience and training.

Selective Policies

In a letter to Joseph B. Jacobs, M.D., chairman of the ARS Socioeconomic Committee, Loeb also points out that Medicares carefully developed FESS coding and payment policies, which continue to be in effect, are being ignored by these payers, even as they adhere to Medicares resource-based relative value scale to set payment. Global surgery policy is inextricably linked to payment values. Thus it would be unreasonable ... for a payer to suggest that it is setting its payments based on the Medicare fee schedule, yet refuse to adopt Medicares global payment policy.

Medicare assigns payment values for FESS assuming that medically necessary subsequent diagnostic endoscopies (31231) or surgical endoscopies with debridement (31237) would be reimbursed separately as outside the 0-day global period.

Healthcare Financing Administration (HCFA) staff, as well as AMA, AAO-HNS and ARC members, were surveyed on appropriate payment values for such services on the assumption the primary procedure would have 0 global days, Loeb notes in the letter.

Clearly, HCFA would have valued the FESS procedures at a much higher level if the procedures had a 90-day rather than a 0-day global period, because under the 90-day global payment policies, the payment would have included postoperative endoscopies or other postoperative services. Any payer who adopts the HCFA fee schedule for FESS without also adhering to Medicares global surgery guidelines wants to have the best of all worlds. However, such a payer policy is unreasonable, Loeb says.

Note: Some of these arguments may not apply if the carriers fee schedule for FESS is not based on RB/RVS.

Reimbursement Tips

Even if a carrier adopts such a policy, the otolaryngologist has some options available that may result in payment for post-FESS services.

Precertification. When endoscopic sinus surgery is scheduled, precertification should be obtained not only for the procedure itself but also for any potential work that may need to be performed after the procedure (i.e., endoscopies, debridements), says Cheryl Odquist, CPC, a coding and reimbursement specialist in San Diego. Odquist recommends otolaryngology practices call the patients carrier after scheduling the surgery with the hospital to determine if the carrier requires precertification. Even if the answer is no, precertification for follow-up debridements or endoscopies should be obtained, she says. Such precertification or predetermination, as some carriers now refer to it addresses the question of medical necessity and would be based on the patients current condition (for example, chronic or acute sinusitis), which may require debridement to prevent recurring sinus infection after the primary FESS procedure. Calling for precertification also lets the otolaryngologist know which diagnoses are required for the carrier to reimburse the debridement, Odquist says.

Tip: When calling in for precertification, you also should remember to ask the carrier if the procedure has a global period so you know whether to use modifiers. If precertification for postoperative procedures is not needed, make sure you document whom you spoke with for future reference.

Modifiers -58 and -79. Some postoperative services are covered even when a procedure has a global period. If the otolaryngologist can show that a subsequent debridement or endoscopy is separate from the original procedure or is more than routine follow-up care, modifier -79 (unrelated procedure or service by the same physician during the postoperative period) should be attached to the secondary procedure when it is billed. Alternatively, if the procedure is preplanned, in some cases it may be appropriate to append modifier -58 (staged or related procedure or service by the same physician during the postoperative period). Precertifying the procedure may facilitate payment of such procedures, because the carrier already has approved the preplanned service.

Documentation. If you are trying to obtain payment for services performed after a FESS procedure from a carrier that assigns such procedures a 90-day global period, the supporting documentation has to back up the claim. You have to be careful to ensure that any post-
operative debridements are extensive, Odquist says, noting that simple removal of cotton pledgets with nasal spray and blood removal from the nares (external nostrils) would likely qualify only for an office visit, which would be included in the carriers global package.

Get Results After Denials

Even with meticulous documentation, some claims are going to be denied when they are first submitted. Inappropriate denials can be appealed, however, which may mean doing as little as calling the nurse at the carrier to prove the medical necessity of the procedure performed. If a simple call doesnt solve the problem, there are other avenues of obtaining satisfactory outcomes, including:

Arrange a meeting with the carriers medical director. During the meeting, the medical director should be asked to justify the decision to establish a 90-day global period for FESS procedures and also provide details on the experience and training of any payer medical consultant cited in defense of the policy.

Request an administrative fair hearing. Or report the carrier to the states Insurance Commissioner. According to the letter from AAO-HNS and ARS outside legal counsel, payers usually are confronted with constraints in how they set their payment levels. For example, payers usually have written policies or contracts with employers, enrollees and/or providers that state that their payment rates will be reasonable. Moreover, many states have insurance laws that explicitly require (such rates be reasonable). Since this policy is unreasonable in that it bases payments on Medicares fee schedule but refuses to adopt Medicares global surgery period, the carrier may be in violation of state law and susceptible to significant legal remedies.

Hold the patient responsible for fees. In some cases, it may be possible to have the patient sign a waiver for postoperative services performed, Odquist says, noting that when patients become aware of this limitation to their health benefits, they are likely to complain to their carriers, which in turn can lead to denials being reversed.

The American Rhinologic Society has instructed its members to include the letter cited earlier in this article when postoperative endoscopies or debridements (31231 and 31237) are denied. This letter can be downloaded at
http://american-rhinologic.org/pdf/LegalBrief.pdf