Otolaryngology Coding Alert

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 the physician, if the operative report contains no mention of tissue removal, then 31267 or 31288 cannot be billed, says Rebecca Cavin, RN, CPC, a coding and reimbursement specialist in La Canada, Calif. If the operative report simply states nasal endoscopy with antrostomy, even though tissue was removed to perform the procedure, all that can be billed is 31256, Cavin says.

Although payment for either 31267 or 31288 may be forthcoming if these codes are billed without supporting documentation in the op note, doing so puts the otolaryngologist at risk for noncompliance if he or she is audited, she notes.

In short, Cavin says, the operative report must show that removal of tissue was a component of nasal/sinus endoscopies. In addition, the summary of the operation performed (at the top of the operative report) also should indicate nasal/sinus endoscopy with removal of tissue as the complete surgical description.

The difference in reimbursement between the two procedures is significant. Whereas 31256 is assigned 7.54 relative value units (RVU) by the National Physician Fee Schedule Relative Value Guide, 31267 has 11.77 RVUs, a 56 percent increase. The payment difference between 31287 with 9.11 RVUs and 31288 at 10.66 RVUsa 17 percent variationalso is noteworthy. In other words, by documenting the procedures correctly, your otolaryngologists reimbursement can be increased, Cavin says.

In addition, both 31267 and 31288 usually are secondary procedures accompanying ethmoid endoscopies (31254, nasal/sinus endoscopy, surgical; with ethmoidectomy, partial [anterior]; 31255, with ethmoidectomy, total [anterior and posterior]). Because both ethmoidectomies are assigned more RVUs than the sphenoid tissue removal, 31288 should be listed after either 31254 (10.75 RVUs) or 31255 (16.16 RVUs) when billing for the procedures. Maxillary tissue removal would be listed ahead of 31254 but below 31255 on the HCFA 1500 form.

Note: If any of these sinus endoscopies are performed bilaterally, the sequence would change, depending on which procedures were bilateral and which were performed on one side only.

In other words, the order in which the procedures are listed on the HCFA 1500 claim form depends on what other procedures are performed, whether they are bilateral and the total number of RVUs assigned to each. This would allow the otolaryngologist to maximize the payment for the procedures by listing those with the most RVUs first.

Frontal Sinus Tissue Removal

Unlike other nasal endoscopies, tissue removal is included in the procedure code for a frontal sinus endoscopy (31276, nasal/sinus endoscopy, surgical with frontal sinus exploration, with or without removal of tissue from frontal sinus).

But occasionally, accessing the tissue via endoscope is difficult, Odquist says. Therefore, another procedure (31070, sinusotomy, frontal; external, simple [trephine operation]) may be performed to remove it.

When this occurs, the otolaryngologist may forget to mention the 31070 at the top of the op note. Consequently, the coder must read through the procedure note carefully, where the frontal sinusotomy likely is described, and then bill for it. Conversely, if the procedure is noted at the top but not in the body of the report, then a corrected report should be dictated before billing for the 31070.

Note: Code 31276 is assigned 16.71 RVUs, while 31070 is worth 9.76.

Amend Pre-certification for Unplanned Removal

Otolaryngologists may perform a CT scan and/or stereotactic guidance on patients to see if any polyp tissue will need to be removed. But occasionally such removal is unplanned, and therefore, has not been pre-certified by the carrier. In this case, otolaryngologists should have their staff who handle pre-certification call the carrier to amend the pre-certification codes that were approved before surgery, says Barbara Cobuzzi, MBA, CPC, president of Cash Flow Solutions, a coding and reimbursement firm in Lakewood, N.J.

Doctors who earn the most communicate well with their surgical coordinating team and make sure their staff are aggressive in terms of getting and amending pre-certifications, Cobuzzi says, adding that doing so helps them earn from 50 to 100 percent more than their colleagues.