Correctly Documenting Endoscopic Tissue Removal can Increase Pay Up
Published on Sat Jan 01, 2000
Otolaryngologists often run into problems when billing for tissue removal performed during a nasal endoscopy. But by clearly documenting each step performed during the procedure, they can ensure that they are reimbursed for all services performed.
Otolaryngologists often remove tissue when performing endoscopic sinus surgery. CPT provides specific codes that describe these procedures, including 31267 (nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus) and 31288 (nasal/sinus endoscopy, surgical, with sphenoidotomy; with removal of tissue from sphenoid sinus).
Avoid Four Main Errors
Errors in coding tissue removal may show up in one of four ways:
1. Billing for removal that was performed but not included correctly in the operative report (upcoding).
2. Incorrectly billing tissue removal when it is inappropriate (upcoding).
3. Not coding the tissue removal when it is performed and described in the body of the operative report but not noted at the top (downcoding).
4. Billing for endoscopy without tissue removal when it is performed and noted correctly in the operative report (downcoding).
The coder often believes that only the root procedure (31256, nasal/sinus endoscopy, surgical, with maxillary antrostomy; or 31287, nasal/sinus endoscopy, surgical, with sphenoidectomy) is performed, when in fact the otolaryngologist removed tissue. In many cases, otolaryngologists do not note the removal of tissue at the top of the operative report, so coders have to read right down to the bottom of the procedure section of the op note to find out they removed sphenoid tissue, says Cheryl Odquist, CPC, an otolaryngology reimbursement specialist with California Health Management Billing, a medical management firm in San Diego, Calif.
To avoid such misunderstandings, Odquist recommends that otolaryngologists provide the CPT codes. The coders function then should be to cross check to ensure the correct code is chosen. Failing that, she urges otolaryngologists to include exactly what the procedure involved in the body of the op note at the top under a heading such as Procedures Performed.
Note: The operative report also must include the reason(s) for the removal of the tissue.
Occasionally, the reverse occurs: The removal of tissue is noted at the top of the operative report but not in the description of the procedure, Odquist says. In the body of the op note, the otolaryngologist will state that he or she went into the ostium with the scope, and the sinuses were clear. But if the sinuses are clear, that means there was no tissue to be removed, she says.
This is a problem because it conflicts with the top of the operative report. Maybe the otolaryngologists intention was to remove tissue before the operation, but then there wasnt any tissue to remove, Odquist says.
Significant Payment Differences
Despite the intent of [...]
