Otolaryngology Coding Alert

HCFA now says otolaryngologists may bill separately for stereotactic guidance (i.e., InstaTrak and similar devices) during functional endoscopic sinus surgery (FESS).

Since the introduction of version 6.2 of the national Correct Coding Initiative (CCI), 61795 (stereotactic computer assisted volumetric [navigational] procedure, intracranial, extracranial, or spinal [list separately in addition to code for primary procedure]) had been considered a component of FESS codes 31254-31256, 31267 and 31276.

The latest CCI (7.0), however, implemented on Jan. 1, 2001, eliminates these edits. Furthermore, the deletions are retroactive to the initial effective date of these edits (Aug. 15, 2000), according to a letter from the medical director of the CCI, Niles R. Rosen, MD, to Frederick A. Kuhn, MD, FACS, president-elect of the American Rhinologic Society and G. Richard Holt, MD, MPH, executive vice-president of the American Academy of Otolaryngology-Head and Neck Surgery. Claims denied on the basis of these edits should be resubmitted, the letter adds.

Rosen, responding to an earlier letter signed by both Kuhn and Holt, noted that the CPT editorial panel had revised the definition of stereotactic computer-assisted navigation code 61795 to include extracranial as well as intracranial procedures. Even prior to this revision, 61795 had been designated an add-on code, which means that the CPT editorial panel, composed of physicians from various specialties and physicians representing HCFA and commercial insurance associations, intended for physicians to use this code in addition to the code for the primary procedure, the letter continues. Thus, the action by HCFA and AdminaStar Federal [the Medicare carrier for Indiana and Kentucky that also develops the CCI] to bundle 61795 conflicts with the very clear decision of the CPT Editorial Panel to explicitly list 61795 as an add-on code.

Billing for 61795

As Stella Almassian, administrator of the department of otolaryngology at Northwestern University in Chicago, points out, Guided surgery can reduce the risk of complications and reduce the length of surgery, saving time and cost. Nonetheless, otolaryngologists are advised not to bill 61795 for sinus surgeries for which stereotactic guidance is not warranted, says Barbara Cobuzzi, MBA, CPC, CPC-H, an independent otolaryngology coding and reimbursement specialist and president of Cash Flow Solutions in Lakewood, N.J.

Physicians should only use and bill for devices when they are truly needed, in complex cases, Cobuzzi warns. She further notes that when 61795 is claimed, the findings section of the operative report should justify the use of stereotactic guidance by referring to prior surgery, opacification or extensive polyps, for example.

If a patient has had prior surgery, such as a turbinectomy, some of the landmarks the otolaryngologist requires may not be there. In such cases, stereotactic guidance allows the physician to work in a sensitive area and not, for example, damage the optic nerve. Therefore it makes sense to bill [61795] for sphenoid and frontal sinus surgery, Cobuzzi continues. In cases where there isnt a significant obstruction of view, the procedure probably isnt medically justified.

When 61795 was modified to include extracranial procedures, Cobuzzi says, coders began to see a sharp increase in the use of 61795 for all FESS surgeries by some surgeons, which very conveniently added additional reimbursement value but not necessarily any real value to the service. This, Cobuzzi says, may have contributed to HCFAs rationale for the now-deleted edits, and if otolaryngologists overuse 61795 again, another set of edits will likely result.

Its appropriate to code 61795 for patients with pansinusitis, isolated sphenoid sinus disease and frontal sinus disease, as well as for revision sinus surgery, orbital exploration, and CSF (cerebro-spinal fluid) leaks, advises Lee Eisenberg, MD, an otolaryngologist in private practice in Englewood, N.J., and a member of CPTs editorial panel and executive committee.

It is not appropriate, however, to bill [61795] in cases of maxillary antrostomy and/or anterior ethmoidectomy, unless there are unusual circumstances, Eisenburg says, noting, even though theres no edit, the anatomy is such that you dont need to use the guidance system.