Otolaryngology Coding Alert

Getting reimbursed correctly for sinosurgery can be difficult. If, for example, an otolaryngologist performs endoscopic sinus surgery on two sinuses, the ethmoidal and the maxillary (31254-31256), some carriers bundle the two procedures together, claiming they are inclusive, even though the Health Care Financing Administration (HCFA) does not bundle them.

The best way around this problem is to use different diagnosis codes for each sinus, says Teresa M. Thompson, CPC, an ENT coding consultant from TM Consulting in Carlsborg, WA. By changing the last digit on the ICD-9 code and applying it to the correct CPT code, the physician makes each diagnosis specific to the individual sinus (473.2, ethmoidal; 473.0, maxillary).

The physician also needs to document the medical necessity of performing both procedures in the operative note, Thompson adds, because if it appears as though the physician removed the maxillary sinus merely to get to the ethmoidal, many commercial carriers will not reimburse the maxillary procedure. She recommends that each procedure be documented individually, and as specifically as possible.

Billing for Bilateral Procedures

According to the 1999 CPT guidelines, if the procedures referred to above were performed bilaterally, the -50 modifier (bilateral procedure) should be attached. However, many insurance carriers are utilizing computer systems that are unable to process bilateral procedures on a one-line item or billing entry. To combat this problem, Thompson recommends billing bilateral procedures on two lines, with the -50 modifier attached to the second claim (see below). Thompson adds that both procedures should be billed at 100 percent, with an expectation of receiving 150 percent for the combined procedure from the carrier. Example two-line entry on claim form:

Box 21: 1. 473.2
Box 24: 31255 1
31255 -50 1

Of course, a patient with severe chronic sinusitis could require work not only on the ethmoidal and maxillary sinuses, but also on the frontal (473.1) and sphenoid (473.3).

There also is a diagnosis code commonly used when two or more sinuses are infected (pansinusitis, 473.8). However, Thompson says, this code does not specify which sinuses are problematic, so it should not be used if the otolaryngologist knows, through the use of an x-ray or CT scan, which sinuses are infected. Instead, the diagnosis codes that are specific to the individual sinuses should be listed on the claim.

Claiming Turbinate Removal Separately

Sinus conditions are often associated with turbinate problems or a deviated septum (470). And, it is not uncommon for the ENT surgeon also to remove the turbinates during sinus surgery or work on sinuses while repairing a deviated septum.

If the physician does remove the turbinate, commercial carriers may bundle it to the sinus procedure(s), saying it cannot be billed separately if the turbinate was removed simply to access the ethmoidal sinus.

Thompson adds that in this scenario, the medical necessity for the turbinate hypertrophy (478.0) needs to be specifically documented so that the removal or resection of the turbinate can be claimed (30130, excision turbinate; 30140, submucous resection) and reimbursed separately.

Get Paid During Global Periods

HCFA defines sinus surgery as having zero global days, while turbinates and deviated septums have a 90-day global period. But some commercial carriers measure global periods differently than HCFA, which complicates how procedures performed after the main surgery should be coded.
Even though a carrier may have a global period for sinus surgery, that doesnt necessarily mean that a physician cannot bill, for example, a sinus debridement after the fact.

However, if the carrier does have a global period for
sinus surgery, the physician will need to indicate on any subsequent surgeries that the procedures were either planned prospectively at the time of the original surgery, or that the second procedure was more extensive than the original procedure, or for therapy following a diagnostic
procedure. The modifier tells the carrier that the physician is still working on the original disease, usually doing something that was discussed as a potential or definite treatment at the time of the original decision for surgery.

When the patient returns for the endoscopic debridement, the code would be 31237-58 (nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement [separate procedure]). If, however, the physician cleans and washes the site in his or her office, the procedure would be billed using code 31000 (lavage by cannulation; maxillary sinus [antrum puncture of natural ostium]) or 31002 (sphenoid sinus).

Instead, some carriers may prefer you to use an office visit (99212-99215) E/M code when procedures are performed in your office instead of the 31000 or 31002, Thompson explains.

Ron Nelson, PA-C, president of Health Services Associates in Fremont, MI, and a representative to the AMA CPT Healthcare Professionals Advisory Committee, points out that some carriers may want you to use E/M codes for irrigation, even though they were designed for another purposeto take a patients history, do examinations, and measure complexity of decision-making. Nelson recommends that unless the payer requests otherwise, codes 31000 and 31002 should be used. He adds that the variability among carriers makes it important to find out the codes and documentation your payer requires.

Also, if the original sinus surgery in question was bilateral, another -50 modifier should be added to the endoscopic debridement (i.e. 31237-50). This, of course, does not apply to the clean and wash (31000, 31002) done in the physicians office.

Note: If turbinate reduction or work on a deviated septum was also performed during the global period at the same time as the sinus debridement, the physician can still bill for the sinus debridement. This is done using the -59 modifier (unrelated procedure) to indicate to the carrier that a separate procedure is being performed on the sinuses, and that it is unrelated to the deviated septum and to the turbinate.