Otolaryngology Coding Alert

Take each of these factors into account to simplify the coding and billing process.

Speaking of Advance Beneficiary Notices (ABNs), rhinoplasty procedures are one example in which a provider should opt to issue a patient an ABN when Medicare considers the rhinoplasty to be cosmetic and therefore not medically necessary.

However, a determination of what is and is not medically necessary should never be left up to the provider’s discretion based on the clinical facts of the case. Rather, physicians and office staff should be aware of the general (and code-specific, if applicable) Medicare policies on medical necessity.

As it applies to rhinoplasties, Medicare has a specific set of guidelines providers must follow when making a determination on medical necessity. Read on for more tips and advice on how to determine whether a rhinoplasty procedure is medically necessary.

Know Medicare’s Rules Specific to Rhinoplasties

A common misconception within otolaryngology practices is that a rhinoplasty is medically necessary as long as it is not for cosmetic reasons. While this is half-true, it’s important that a provider familiarize themselves with Medicare’s rules on what qualifies as a medically necessary reason for performing a rhinoplasty.

According to Medicare, “When nasal surgery is performed solely to improve the patient’s appearance in the absence of any signs and/or symptoms of functional abnormalities, it is considered cosmetic Z41.1 (Encounter for cosmetic surgery) and will be denied as non-covered.” This applies to all rhinoplasty CPT^® codes (30400-30450).

While this might seem like a relatively straightforward set of guidelines, Medicare goes one step further by outlining the specific conditions in which a rhinoplasty (or any nasal surgical procedure) is considered medically necessary:

• Birth defects, e.g., congenital cleft lip and/or palate, and any other congenital craniofacial deformity, when associated with severe functional impairment;
• Significant, documented nasal trauma with distortion within the three months prior to surgery that signifi­cantly compromises the nasal airway and can only be corrected by combined septo-rhinoplasty, as opposed to delayed open reduction of nasal and septal fracture, (CPT^® 21335, Open treatment of nasal fracture; with concomitant open treatment of fractured septum);
• Choanal atresia;
• Cancer;
• Septal infection with saddle deformity; or
• When there is documentation that obstructed nasal breathing due to septal deformity is not amenable alone to septoplasty due to significant loss of structural integrity of the septum by external nasal traumatic deformity.

Vestibular Stenosis Requires an Additional Set of Guidelines

The conditions above apply to situations in which the patient is not being treated for vestibular stenosis. The guidelines become even more specific when you are coding for a rhinoplasty treating nasal vestibular stenosis. According to Medicare, each of the following conditions need to be met in order to reach medical necessity for CPT^® code 30465 (Repair of nasal vestibular stenosis [eg, spreader grafting, lateral nasal wall reconstruction]):

• Nasal airway obstruction is causing significant symptoms (e.g., chronic rhinosinusitis, difficulty breathing);
• Obstructive symptoms persist despite conservative management for three months or more, which includes, where appropriate, nasal steroids or immunotherapy;
• Photographs demonstrate an external nasal deformity;
• There is significant obstruction of one or both nares, documented by nasal endoscopy, computed tomography (CT) scan or other appropriate imaging modality; and
• Airway obstruction will not respond to septoplasty and turbinectomy alone.

Remember: If that set of guidelines isn’t daunting enough, Medicare includes one additional qualifying factor to reach medical necessity on rhinoplasty procedures. “If a physician performs a rhinoplasty (with or without a septoplasty) to treat a patient with obstructive sleep apnea, the rhinoplasty is not to be considered a medically necessary procedure,” says Kimberly Quinlan, CPC, senior medical records coder for the University of Rochester Medical Center’s Department of Otolaryngology in Rochester, New York. “These guidelines remain true whether the rhinoplasty is performed alone or alongside another associated procedure such as a uvulopalatopharyngoplasty (UPPP),” Quinlan adds.

Include the Appropriate Documentation

In the cases that a physician performs a rhinoplasty for medically necessary reasons, you will want to send the code out on paper (and electronically, for timely filing) along with the following set of documentation:

• Results of nasal endoscopy, CT or, other appropriate imaging modality documenting nasal obstruction;
• If there is an external nasal deformity, preoperative photographs showing the standard 4-way view — base of nose, frontal view, and right and left lateralviews;
• Relevant history of accidental or surgical trauma, congenital defect, or disease (e.g., choanal atresia, nasal malignancy, abscess, septal infection with saddle deformity, or congenital deformity);
• Documentation of duration and degree of symptoms related to nasal obstruction, such as chronic rhinosinusitis, mouth breathing, etc.; and
• Documentation of results of conservative management of symptoms.

Follow this Advice when Billing for Cosmetic Rhinoplasties

If your physician performs a rhinoplasty that does not meet the criteria as medically reasonable or necessary, you will want to take some separate measures when billing out to the patient. These measures include informing the patient of the denial through the issue ofan ABN.

“A rhinoplasty performed for cosmetic reasons will be denied by Medicare due to the statutory exclusion for cosmetic surgery,” explains Jennifer M. Connell, CPC, CENTC, CPCO, CPMA, CPPM, CPC-P, CPB, CPC-I, CEMA, Owner of E2E Health Solutions in Victoria, Texas. “For statutory exclusions, ABNs are voluntary, not required. Even though they are not required, it is highly recommended that the physician issue an ABN — as doing so would eliminate any possible confusion or future complaint from the patient and/or Medicare,” Connell says.

Exception: When it comes to cosmetic surgery, there is one exception in which Medicare may reimburse for the procedure given the appropriate justification and documentation. According to Medicare, a cosmetic surgery may be covered in the case of a “prompt (as soon as medically feasible) repair of an accidental injury or the improvement of the functioning of a malformed body member.”

For example, if a physician performs a rhinoplasty to reconstruct a patient’s nose following an automobile accident, Medicare will reimburse for the procedure. This is true even if the patient does not have any objectively identifiable symptoms from the injury.