Otolaryngology Coding Alert

Find out if the new codes will ease PNN destruction reimbursement woes.

Otolaryngologists have tackled challenges that accompany chronic rhinitis with a barrage of therapies over the years, sometimes with little to no improvement in the patient’s condition. For patients who haven’t responded to first-line treatment, there is another option: posterior nasal nerve (PNN) ablation, which can be performed in the office.

Remember: You now have two new CPT^® codes available to report PNN destruction based on the technology used: 31242 (Nasal/sinus endoscopy, surgical; with destruction by radiofrequency ablation, posterior nasal nerve) for radiofrequency ablation using RhinAer^® and 31243 (Nasal/sinus endoscopy, surgical; with destruction by cryoablation, posterior nasal nerve) for cryoablation via ClariFix^®.

In Otolaryngology Coding Alert Volume 26, Number 2, we examined proper coding for PNN neurolysis. In this issue, we’ll explore chronic rhinitis ablative therapy payer policies and how some have made obtaining payment quite challenging, along with advice on overcoming these obstacles and strengthening your case for reimbursement.

Keep Abreast of Policy Updates

If your otolaryngologist plans to use ablative therapy for chronic rhinitis, you should first contact the payer ahead of time to determine their reimbursement criteria and review what your contract with the payer allows your practice for reimbursement policies.

Insurers usually update their payment policies for certain medical procedures on an annual cycle. However, they may make changes to their reimbursement policies outside of this review cycle, which can create a bit of a roller-coaster effect for coders, adding to the confusion surrounding how to report these services and whether providers will get paid for them. Some payers will reimburse these ablation procedures, while others won’t, despite the addition of the new CPT^® codes.

“Also, keep in mind that although a policy may change for a payer, practices have negotiated contracts with payers and there may be reimbursement policy defined in the specific contract that the practice has with the payer,” notes Barbara J. Cobuzzi MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, CMCS, of CRN Healthcare Solutions of Tinton Falls, New Jersey. “If the payer makes changes outside the contract, this should be pointed out to the payer and appealed for payment.”

Beware, Rhinitis Ablative Tx Reimbursement Can Vary

In December 2023, the Healthy Blue Managed Medicaid program for North Carolina released a position statement noting that “Minimally invasive treatment of the posterior nasal nerve, such as cryotherapy or radiofrequency therapy, to decrease the symptoms of allergic or nonallergic rhinitis is considered investigational and not medically necessary in all cases” (https://provider.healthybluenc.com/dam/ medpolicies/healthybluenc/active/policies/mp_pw_e000642.html).

Therefore, this payer will not reimburse you for any such services as part of its reimbursement policy. “But if your practice’s contract with BlueCross BlueShield of NC states that treatments that are proven to be medically necessary and effective are payable, this arbitrary policy should be fought, and the practice should try to get the payer to pay for the ablative treatment based on the science showing that the treatment is medically effective and necessary for patients suffering from chronic rhinitis. This can become a disagreement between your clinical experts and their clinical experts who are probably not otolaryngologists. Practices may be successful in getting appealed claims paid,” Cobuzzi advises.

Key: If a physician gets authorization based on efficacy and medical necessity or via a peer-to-peer review, preferably with another otolaryngologist, the provider may still get reimbursed despite these coverage policies.

“Because there is a risk that the payer may dig in their heels and not pay for these procedures, it is a best practice for the medical practice to have the patient sign an informed waiver where the patient agrees to pay for the treatment and is told the cost to them, should their third-party payer not pay for the service, which has been proven medically effective,” Cobuzzi adds.

Know Where To Go for Help

“Remember that all employer-sponsored insurance plans are regulated by the Employee Retirement Income Security Act [ERISA], not your state insurance laws,” Cobuzzi says. “ERISA has minimum requirements and coverage protections for patients. Insurance companies count on practices being ignorant about ERISA and accepting the rules as dictated by the payer. If the patient is covered by an employer-sponsored insurance plan, turn to ERISA for guidance and assistance in appealing denials from the third-party payers.”

The device companies can even lend a hand. Aerin Medical, the manufacturer of RhinAer, has a robust reimbursement center that assists practices with pre-certification and appeals to third-party payers. Similarly, Stryker has an active reimbursement department to answer client questions and support customers in the process of getting paid for ClariFix.

Bottom line: When submitting claims for chronic rhinitis treatment via ablation of the PNN, double-check to ensure the physician documentation is accurate and the coding is correct. And remember you can reach out to the device company’s reimbursement support department for assistance with appeals and convincing the payer to reimburse the procedure.