Otolaryngology Coding Alert

Know when an unlisted code is the best option.

In numerous specialties, there is a general skepticism among coders surrounding the use of unlisted codes for certain surgical procedures. In many ways, this skepticism is reasonable.

For providers, there’s often a disincentive to use unlisted codes for the primary reason that they are lacking a proper fee schedule. When providers are compensated based on relative value units (RVUs) — and these unlisted procedures lack RVUs — the notion of submitting a “blank” code to document a complex, time-consuming procedure can leave a provider feeling understandably uncomfortable. And, the process of getting properly compensated is equally arduous, causing providers, coders, and billers to shy away from using unlisted codes.

Having a firm grasp on when, where, and how to utilize unlisted codes is a crucial bit of knowledge for any coder, provider, or administrator. While there are no universal rules in place, there are certain measures you can take to help guide you in your decision on when and when not to bill out a procedure with an unlisted code.

Make a Calculated Decision

So, what’s the alternative to using unlisted codes? Providers will often settle for a few inconsistencies if it means applying a code with an established fee schedule. For any coder, this should trigger an immediate red flag. Not only is there risk of committing fraud, but improper documentation of a procedure can affect patients from the perspective of both insurance payments and electronic health records (EHRs). Factoring in the notorious difficulty providers face when attempting to get payment for unlisted codes, it seems that neither option is ideal.

There are also long-term ramifications in attempting to fit new technologies and procedures without an accurate CPT^® procedural description into an existing CPT^® code, explains Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, AAPC Fellow, Vice President at Stark Coding & Consulting LLC, in Shrewsbury, New Jersey. “Those ramifications come when the specialty ultimately does acquire a new code for the service. If the service has been submitted previously under an existing CPT^® code, RVUs from the prior code will be removed and reallocated to the new code’s fee schedule. However, if the procedure has previously been submitted using an unlisted code, an entirely new fee schedule will be created without the distribution of RVUs elsewhere.”

Determining value of future codes not only impacts the specialty, but other procedures of a comparable nature as well. This emphasizes the importance of using unlisted codes in cases where there is no code available that accurately describes the services performed.

Unlisted Example 1: Endoscopic Sphenopalatine Artery Ligations

It appears there’s some degree of debate as to which codes correctly apply when a physician performs an endoscopic sphenopalatine artery ligation. Physicians will pull out every stop in attempting to defend one code versus the next as it applies to endoscopic sphenopalatine artery ligation. But, our goal is to convince you that only one universal code should, at the end of the day, be listed alongside this procedure:

• 31299, Unlisted procedure, accessory sinuses

Just looking at the descriptor, we certainly get why providers aren’t comfortable submitting the code in this situation. It’s analogous to writing a novel on the varying cultural dynamics between the North and the South during the Civil War and being forced to title it as “History Book”. It doesn’t exactly convey the message of what’s inside, or the effort invested into writing the book.

But, in the case of endoscopic sphenopalatine artery ligation, the fact remains that no listed CPT^® codes fit the bill. Let’s take a look at some examples:

• 30920, Ligation arteries; internal maxillary artery, transantral

This one’s close, but doesn’t quite make the cut. 30920 is an open procedure, with the physician making an incision in the upper gums to reach the maxillary artery (the sphenopalatine artery is a terminal branch of the maxillary artery). CPT^® rules state that you cannot use an open code when a procedure is performed via an endoscopic approach. If there is no code that describes the endoscopic approach, rules state to use an unlisted code.

• 31238, Nasal/sinus endoscopy, surgical; with control of nasal hemorrhage

On the surface, this code might seem more appropriate. However, the physician would be doing themselves a disservice to apply this code to an endoscopic sphenopalatine artery ligation, explains Kimberly Quinlan, CPC, senior medical records coder for the University of Rochester Medical Center’s Department of Otolaryngology in Rochester, New York.

“If you look at the RVUs associated with 31238, it’s clearly meant as a code where the surgeon uses an endoscope and Bovies some bleeding,” Quinlan reiterates. “This code ultimately doesn’t reflect the effort it takes to dissect the sphenopalatine artery out and ligate it.”

Quinlan goes on to outline how she would approach this scenario using an unlisted code. “Financially, and more technically correct, would be to use the unlisted code 31299 and argue that one should get paid on the scale of the transantral internal maxillary ligation code — because that’s what the sphenopalatine ligation is really replacing.”

When submitting 31299 for this procedure, you want to give the payer a reference for valuing the service. It is best to give them a CPT^® code to compare it to along with a percentage (of work performed) of that CPT^® code so that a value can be assigned to the unlisted code. Place this information in box 19 of the CMS1500 Claim.

In this case, it might be recommended to compare 31299 to 31238, but since it requires additional effort and risk to dissect the sphenopalatine artery and ligate it, it would be worth approximately 150 percent of 31238. However, it will be up to the physician to determine the relative worth of the procedure.

Unlisted Example 2: Endoscopic Resection of Sinonasal/Skull Base Tumor

Here’s another scenario in which physicians and coders alike might opt for an incorrect code (for less reimbursement) in order to avoid the hassles of submitting an unlisted code. Rather than risking a denial for an unlisted code, a physician or coder might prefer the idea of billing out for endoscopic resections of sinonasal/skull base tumors with one of the following:

• 31276, Nasal/sinus endoscopy, surgical with frontal sinus exploration, with or without removal of tissue from frontal sinus 
• 31267, Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus 
• 31288, Nasal/sinus endoscopy, surgical, with sphenoidotomy; with removal of tissue from the sphenoid sinus
• 31255,  Nasal/sinus endoscopy, surgical; with ethmoidectomy, total (anterior and posterior)

If the documentation supports the removal of a tumor, then each of these procedure codes are incorrect. The removal of tissue is not equivalent to that of a tumor, and, from a coding standpoint, the use of the above codes to document tumor removal could put a practice at risk in case of an audit. That leaves you out of options when considering which endoscopic CPT^® code fits best for these procedures. For endoscopic resections of sinonasal and skull base tumors, you’ll want to apply the unlisted accessory sinus code 31299.