Otolaryngology Coding Alert

Denials for services ethically claimed are an irritating and fairly frequent occurrence for otolaryngology practices. Even more annoying, however, are denials when the claims were correct. Fortunately, the otolaryngologist is not without resources when incorrect denials occur.

The appeals process can be frustrating, time-consuming and can yield relatively little. Still, it offers a way for ENTs to make their case and gain reimbursement for procedures that were inappropriately denied.

Step 1: Compare What You Charged
With What You Receive

One reason procedures may not be reimbursed is inappropriate bundling by payers. Even if all National Correct Coding Initiative (NCCI) edits were checked before the claim was made, some carriers tend to bundle a wide range of procedures, says Barbara Cobuzzi, MBA, CPC, CHBME, president of Cash Flow Solutions, a physician reimbursement consulting firm in Lakewood, NJ, whose clients include otolaryngology practices.

She notes that many carriers will inappropriately rebundle endoscopic sinus procedures and turbinates. Meanwhile, endoscopic ethmoids, maxillaries and sphenoids may be rebundled into the sphenoidotomy.

For example, if you performed an ethmoidectomy (31254, nasal/sinus endoscopy, surgical; with ethmoidectomy, partial [anterior]), a 31267 (nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus) and a sphenoidotomy (31287, nasal/sinus endoscopy, surgical, with sphenoidotomy), I would expect managed care carriers, at a minimum, to allow about $1,800-$2,000. Therefore, if their allowable is only in the $900 range, you know they arent processing all your procedures. So even if you dont know the payers fee schedules because they wont give them out, you should appeal if the total is too low, says Cobuzzi.

Carriers also inappropriately assign global periods. For example, sinus surgeries, esophagoscopy and laryngoscopy all have 0 global days, but other procedures still may be bundled to them, with a global package cited as the reason.

Cobuzzi relates a scenario where the otolaryngologist visited the patient in the hospital the day before performing an esophagoscopy (43200, esophagoscopy, rigid or flexible; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]). And even though the ENT billed for a hospital visit, the rounds made by the doctor the previous day were bundled into the 43200, when in fact the procedure has 0 global days, which means the rounds are actually billable. Some carriers also say the days following such procedures are part of the global period. But they clearly are not in the instance of 0 global days, Cobuzzi maintains.

Step 2: Keep Appeals Letters Simple

In another example of incorrect claim denial, a nasal endoscopy (31237, nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement [separate procedure]) was denied and a consultation was downcoded.

Cobuzzi handled the appeals process for the otolaryngologist in this case. After determining that the nasal endoscopy should have been paid and the consult level should not have been downcoded, she sent the following letter to the carrier on the physicians letterhead:

Dear Sir or Madam:

This letter is being written to appeal the downcoding of the level of consult and the dropping of the -25 modifier and non-payment of the nasal scope and biopsy. The patients name is John Doe, his ID number is _____________, and the date of service was 1/5/98.

I have enclosed the notes from the service. As you can see, the doctor not only performed an E/M service but also performed a nasal endoscopy (31237) for diagnostic purposes. However, your Explanation of Benefits (which is enclosed) indicates you paid only for the 99234 (observation or inpatient hospital care, comprehensive history and exam, low-complexity medical decision making) with a -25 modifier (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) attached, but not for the diagnostic endoscopy in the nose. We are, therefore, sending the legible office notes in the form of a consult.

By notification of these notes, we are requesting that you pay the nasal endoscopy in addition to the consult. The notes justify both services very clearly. We will expect prompt payment, as payment already has been unreasonably delayed on your part.

Note: This appeal netted the otolaryngologist an additional $293 not paid for on the original EOB.

Sometimes, however, despite the strength and logic of the argument, the first avenue of appeal still will be denied.

In the following example, which involves a total thyroidectomy (60240, thyroidectomy, total or complete), a second procedure, 60512 (parathyroid autotransplantation [list separately in addition to code for primary procedure]), was denied and rejected by a Medicare carriers post-payment review. So Cobuzzi had to write the following letter to request a fair hearing appeal:

Dear Sir or Madam:

This letter is being written to request a Fair Hearing appeal on non-payment of surgery done on John Doe (HIC
Number ______________, date of service 1/1/97). This payment denial was further denied by Post Payment Review on 4/7/97, despite relevant appeal, as attached.

As indicated on the Post Payment Review letter, the denial is inconsistent. Given the surgery included in a total thyroidectomy, it is impossible to meet the requirements given to be paid for the parathyroid autotransplantation.

The attached operative report indicates that both a total thyroidectomy (60240) and an implantation of the parathyroid gland (60512) were performed. [The Medicare carrier] has denied the payment for 60512, indicating that 60500 (parathyroidectomy or exploration of parathyroid[s]), 60502 (re-exploration), and 60505 (with mediastinal exploration, sternal split or transthoracic approach) must be charged in order to be paid for 60512.

However, all three of these codes are considered component parts of 60240 and are therefore bundled with it.
It is impossible to bill 60240 and also bill 60500, 60502 or 60505; thus, it has been made impossible to be paid for 60240 and 60512, despite the fact that they are not considered component parts and are not, therefore, considered bundled by NCCI.

Please review the attached appeal, denial and operative report for this surgery. I am confident that you will reverse this denial and pay for 60512 on reviewing this appeal and the operative report.

I am therefore requesting either a medical record review fair hearing, or, if necessary, a telephone fair hearing. The operative report has been enclosed for your review for this hearing. In advance, thank you for your review of this claim and appeal.

This time, the appeal was successful. The Fair Hearing appeal was accepted and the physician received $285.34 for the 60512.

Note: According to CPT 1999, the 60512 may be filed together with a 60240.

Cobuzzi calls the successful appeal a victory on principle rather than for the money, since we only received $285. Still, the experience offers some insights into how such appeals may be handled and may affect future claims.

Step 3: How to Make Your Case

All payers should have an address where appeals may be filed, though it may go by another name, such as issues and resolutions or correspondence, says Kathy Zmuda, CPC, lead inpatient coder for CIGNA Healthcare in Phoenix, AZ.

Once it has been established that the error was made by the payer, a simple explanation of the case should be written so the person who reviews the letter for the carrier understands the complaint, Zmuda says.

If the issues in the appeal relate to medical necessity or medical protocol, the otolaryngologist should be asked to write a clinical letter as well, but Zmuda recommends always putting the simple cover letter on top, with a reference to the physicians note.

When making the case for the physician, you should cite well-established standards of coding, such as those established by Medicare, the American Medical Association (AMA), or the American Academy of Otolaryngology. For commercial carriers, Medicodes Coding Illustrated provides useful ammunition. For example, both Coding Illustrated and the National Correct Coding Initiative indicate that endoscopic sinus surgeries on different sinuses arent bundled.

Zmuda also recommends sending the EOB in question as well as a copy of the operative report, both of which should be referred to in the cover letter. Also, any relevant information from the patients chart, such as photographs, should be included, along with any pre-certification documentation. Receiving pre-certification will not guarantee payment, but it does help that you asked before you performed the procedure.

Basically, you should include all your information to support your case and make your case simply, Cobuzzi says. She also requests that the appeal be reviewed by a board-certified otolaryngologist, and if that physician still finds for the payer, she asks for his name and phone number so that the otolaryngologist billing for the service can talk directly to him.

The appeals letter should end by stating that additional monies are anticipated if the appeal is resolved successfully, with an appropriate address where the payment can be forwarded.

If the appeal is unsuccessful, Cobuzzi says, she files it with the state insurance commissioner (for private carriers) and with the HCFA regional office (for Medicare carriers). She also sends copies of the correspondence to the patient so he or she is aware of what is going on.

Cobuzzi notes that contracts between carriers and physicians also affect coding and may affect denials. Some contracts, for example, may state that payment will be offered based on the payers own utilization standards. These standards may be arbitrary and often work in favor of the insurance company, not the physician, she says.

These contracts may also contain particularly low reasonable and customary fees, especially in the case of managed care carriers. But Cobuzzi stresses that any contractual issue is beyond the scope of an appeal.

You cant appeal a bad fee schedule, she says. If they have a policy where they pay third and fourth procedures at 25 percent, for example, you cant appeal that.