Otolaryngology Coding Alert

When a patient who years earlier had a nasal fracture requires treatment to repair damage originally caused by the fracture, otolaryngologists must code the patients signs or symptoms carefully. Carriers are likely to deny the claim as cosmetic unless the diagnosis codes and supporting documentation clearly indicate the procedure was medically necessary.

Getting the diagnosis codes right is critical in these situations, says Emily Hill, PA-C, CPC,, the managing partner of Hill and Associates, a coding reimbursement firm in Wilmington, N.C. A patient with a deviated septum, for example, amy be examined by the otolaryngologist, who then decides to perform a septoplasty (30520, septoplasty or submucous resection, with or wothout cartilage scroing, contouring or replacement with graft). To get paid for the procedure, Hill says, the otolaryngologist will need to provide proof that it was not performed for cosmetic reasons. In practical terms, that means providing the correct diagnosis codes.

For example, a young man breaks his nose in a car accident. The fracture (802.0, fracture of nasal bones, closed) is treated in a closed manner (21320, closed treatment of nasal fracture, with stabilization). Because of the accident, he has a deviated septum and experiences frequent episodes of sinusitis and mouth breathing. Through the years, he has been treated several times for acute sinusitis (461.9), but the breathing problems and the frequency of sinus infections continue to worsen. The acute sinusitis was treated occasionally via nasal endoscopy (31231, nasal endoscopy, diagnostic, unilateral or bilateral[separate procedure]), while at other times, the patient received an exam and prescription.

Eventually, as the problem worsens, the otolaryngologist talks to the patient,re-examining his history. The physician discovers the nasal fracture and decides to perform a septoplasty.

When the otolaryngologist bills for the procedure, the deviated septum (470) certainly should be reported, but it may not be enough. Just because the septum is deviated doesnt mean the carrier will pay to have the patients nose straightened. So a deviated septum needs a supporting diagnosis, or signs or symptoms, Hill says. The carrier needs reasons, such as the patients problems with breathing, possibly sinusitis or chronic rhinitis (472.0). If the problem is that they have a resulting deviated septum, theyre going to have to show that its creating health related concerns for the patient, other than just looks.

Depending on the circumstances, these diagnoses could include chronic rhinitis, chronic sinusitis (473.2, ethmoidal; 473.3 sphenoidal), or signs or symptoms such as mouth breathing (784.9). Otolaryngologists also should add ICD-9 code 905.0 (late effect of fracture of skull and face bones) to the septoplasty code to indicate that there was a previous nasal fracture and that the current problem is directly linked to it, Hill adds. Another ICD-9 code738.0, acquired deformity of nosegives the carrier additional information, she notes.

When billing for the procedure, you always code the diagnosis first. The additional codes let the carrier know the problem relates to an old nasal fracture, Hill says.

If more than one service is provided to a patient with problems relating to the late effects of a nasal fracture, the otolaryngologist also must ensure that the diagnoses being reported are linked to the proper, corresponding CPT code for the procedure or service performed, says Kathy Zmuda, CPC, lead inpatient coder for CIGNA Healthcare in Scottsdale, Ariz. If the diagnoses arent linked to the corresponding procedures, the carrier may deny the claim, Zmuda says.

Improperly linked diagnosis codes are the main reason such claims are rejected, Zmuda explains. If carriers are kicking out such claims as cosmetic, thats why.

Problem Worse With Rhinoplasty

If the required procedure is a rhinoplasty the hurdles to payment are significantly heightened because many carriers automatically reject this procedure as cosmetic, says Barbara Cobuzzi, CPC, MBA, president of Cash Flow Solutions, a coding and reimbursement firm in Lakewood, N.J.

Payers have an automatic edit on rhinoplasties, Cobuzzi says. Anytime a procedure like 30400 (rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip), 30410 (rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip), or 30420 (rhinoplasty, complete; including major septal repair) is billed, they dont even look at the diagnosis, they bounce it as a cosmetic procedure. We send the op note with the claim, and its obvious they dont even read it or look at the diagnosis for that matter, she contends.

Cobuzzi cites the following real-life example. An adult whose nose had been broken 20 years earlier was having difficulty breathing. Accordingly, the physician performed a rhinoplasty that included major septal repair and billed 30420. The otolaryngologist also billed for a bilateral submucous resection of turbinates, which is indicated by the -50 modifier (30140-50). The claim was denied, as was the appeal. It was paid only after a second appeal was requested.

Cobuzzi believes the claim may have been denied on appeal because there was an element of the procedure that was cosmetic. She notes, however, the otolaryngologist could not have performed the necessary reconstructive work without also doing the cosmetic repair.

Some payers try to ascertain what percentage of the procedure(s) was functional and what percentage was cosmetic and pay according to that. But its absurd, because you cant do one part without the other, she explains.

Medical Records Available for Children

Obtaining payment for late repair of a fracture may be easier if the original damage occurred when the patient was a child. The attending physician at the time may determine that the damage will not reveal itself until the child goes through a growth spurt during adolescence. Because childrens medical records are kept until, and even beyond, they reach 18 years of age, copies of those records may be obtained that can be useful in proving medical necessity when nasal repairs are necessary after the patient reaches adulthood.

For example, a two-year-old girl falls on her face twice within a month. The otolaryngologist checks the bruises on her nose and notes that the child may have incurred damage that will present itself in the future. When the girl is 16, her nose is deformed, and she undergoes a rhinoplasty. The otolaryngologist who performs the procedure acquires copies of the girls medical records and includes the notes of the physician who saw her when the potential problem was first mentioned.

Of course, Cobuzzi says, the payer still may deny the procedure as cosmetic even though the nose was broken years ago. Therefore, documentation of the current functional problems caused by the late effects of the fracture is critical. Both itemsthe old medical records and the current documentation of the patients problemsare valuable when seeking reimbursement.

Cobuzzi also recommends that otolaryngologists take photographs of patients who require rhinoplasties for medical purposes. Such pictures can have a dramatic impact during an appeal, she says.

Regardless, otolaryngologists should have patients sign a waiver that clearly states that if approval from the carrier is not forthcoming, the patient agrees to pay for the procedure before performing it. Cobuzzi notes that some otolaryngologists collect the fee from the patient in advance and refund it if the carrier reimburses them.

If the patient has to pay for a procedure that is deemed medically necessary because a third-party payer refuses to pay for it, he or she should file a complaint with the state department of insurance or the arbitration board, Cobuzzi recommends.