Otolaryngology Coding Alert

Plus: Outline these key terms in the op report.

For the most part, medical coders don't necessarily need to break out of their comfort zone on a regular basis when working on their established specialty. While you've always got to be alert and aware to any potential mistakes, coders can usually take comfort in knowing that the code set at their disposal remains constant on a day-to-day basis.

With that being said, coders of various surgical specialties need to have a plan in place for when new surgical techniques and technological advances get introduced to the practice. In the case of otolaryngology, surgeons are revising and refining their techniques on a regular basis, but entirely new surgical procedures are far less commonplace. Among various other procedures, the past year has introduced a brand-new nasal implant procedure for nasal vestibular stenosis that coders want to take note of in case it is introduced to their practice.

Read further for a full coding breakdown on the Latera^® Absorbable Nasal Implant procedure.

The Latera^® Procedure Defined

More and more physicians are considering the use of a new absorbable nasal implant procedure known as Latera® for treatment of nasal valve collapse. According to the manufacturer, Spirox, "The Latera^® Absorbable Nasal Implant is indicated for supporting nasal upper and lower lateral cartilage. The product is a medical device implant, comprised of a PLLA-PDLA copolymer that is absorbed over a period of approximately 18 months. The Implant is placed with a disposable delivery device." Furthermore, "The implanted graft acts as a supporting beam to prevent subsequent nasal valve collapse and thereby significantly reduce nasal obstruction and improve breathing."

Code Unspecified for Absorbable Nasal Implants

Now that you have an understanding of how the procedure works, you need to establish a firm basis on how to properly code it. At first glance, a coder might feel inclined to apply code 30465 (Repair of nasal vestibular stenosis [eg, spreader grafting, lateral nasal wall reconstruction]). In fact, if you were to exclusively look at the manufacturer's recommendations on how to code the Latera procedure, you would be instructed to use code 30465. On reviewing the code, it makes sense to apply 30465, since the Latera^® implant is a graft which repairs nasal vestibular stenosis.

However, the American Academy of Otolaryngology – Head and Neck Surgery (AAO-HNS) recently came out with information contradicting the manufacturer's suggestions. Instead of using 30465, the AAO-HNS suggests that the only appropriate code for this procedure is 30999 (Unlisted procedure, nose). Consider the following justification from the AAO-HNS:

• "The placement of an absorbable implant, such as Latera^®, involves substantially less work, time, and effort than nasal valve repair using traditional rhinoplasty techniques, such as spreader or alar batten grafting. Under its current valuation, CPT^® 30465 is assigned 120 minutes of intraservice (i.e. skin to skin) work, and it is nearly always performed in a facility setting. As placement of an absorbable nasal implant to treat valve collapse takes far less time than this and can be performed in the office setting, using CPT^® 30465 to report this service would result in significant overpayment. Lastly, given the size of the discrepancy in time and work between traditional valve repair and placement of an absorbable nasal implant, appending modifier -52 (reduced services) also would not be sufficient to account for this difference. As such, CPT^® 30999, (Unlisted procedure, nose), is the most appropriate code to use to report placement of an absorbable implant, such as Latera^®, to treat nasal valve collapse."

Note: Apply modifier 50 (Bilateral procedure) when surgeon performs the procedure bilaterally.

Identify Latera^® in an Operative Note

You now have enough justification to use 30999 when the surgeon performs a Latera^® absorbable nasal implant procedure. The last key to the puzzle is to properly identify the procedure in an operative note. Consider this example portion of an operative note from the manufacturers of the Latera^® absorbable nasal implant procedure:

"The nasal mucosa was incised immediately cranial to the alar rim and the cannula was advanced through the incision along the line drawn. Using the cannula, a dissection plane was created over the upper lateral cartilage. At the junction with the nasal aspect of the maxillary bone, the cannula was brought superficial to the bone. Using the 16-gauge cannula, a dissection plane was created above the periosteum on the superficial aspect of the maxillary bone. The cannula tip was advanced to the target marked 6 mm cranial to the boney/cartilaginous junction using palpation on the surface of the skin. Once the destination was obtained and the dissection was completed, the skin on the nose was normalized, and the cannula was inspected to determine if its tip was at a sufficient depth. Once it was determined that the cannula tip was at a sufficient depth, the polymer implant was delivered and the cannula withdrawn."

"This operative note details the process in which the area for the Latera^® graft is measured and the Latera^® graft inserted," 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.

In order to confirm that the surgeon took all the appropriate steps at documenting the nasal implant procedure, you will want to key in on a few fundamental terms. For example, you will want to make sure the operative note references terms such as the "polymer implant" for the nasal implant and the use of a "cannula" as a means of inserting the implant.

Confirm Medical Necessity

Lastly, it is important for both you and your provider to confirm that the absorbable nasal implant procedure is medically necessary and will receive proper reimbursement. These MCG™ Care Guidelines explain that repair of nasal vestibular stenosis or alar (lower lateral) collapse is considered reconstructive and medically necessary when all of the following criteria are present:

• Prolonged, persistent, obstructed nasal breathing due to internal and/or external nasal valve compromise;
• Internal valve compromise due to collapse of the upper lateral cartilage and/or external nasal valve compromise due to collapse of the alar cartilage resulting in an anatomic mechanical nasal airway obstruction that is a primary contributing factor for obstructed nasal breathing; and
• Other causes have been eliminated as the primary cause of nasal obstruction (e.g., sinusitis, allergic rhinitis, vasomotor rhinitis, nasal polyposis, adenoid hypertrophy, nasopharyngeal masses).

"When submitting the claim for the unlisted code, equate the Latera^® graft implant to 30465, but give the payer the percentage of intraservice skin to skin time and effort required for the Latera^® graft implant versus the 120 minutes allocated to the RVUs [relative value units] for spreader grafting," relays Cobuzzi. "Also, inform the payer, in addition to the reduced percentage of time involved, that this unlisted procedure also involves the cost of the material for the Latera^®, since the procedure is usually performed in the office."

Cobuzzi continues: "Let the payer know that they are saving the fees associated with the facility and anesthesiologist associated with the traditional spreader graft used with 30465. Additionally, the patient is expected to be back at work and productive - not laid up as long as expected with a traditional spreader graft - when a Latera^® graft is used."

Keep in mind: Individual payers may recommend pre-authorization of services prior to the use of the Latera^® Absorbable Nasal Implant. Additionally, make sure you brush up on how to properly bill for unlisted procedures in order to achieve appropriate reimbursement.