Otolaryngology Coding Alert

Get in on the ground floor of this exciting new technology.

Physicians and researchers within the otolaryngology specialty are always pushing the technological boundaries of new and emerging medical treatments. For instance, you’ve seen it in recent years with the introduction of the Latera and Sinuva nasal implants, in addition to some exciting advancements involving cochlear implant technology.

More recently, you may have heard about Vivaer, a brand-new device for treating nasal obstruction involving the nasal valve, inferior turbinates, or soft tissue obstructions on the septum. This nasal airway remodeling technology has otolaryngologists excited about its potential to shape the ENT landscape. But in addition to the learning curve on the physician’s end of the spectrum, coders also need to be fully prepared to code this emerging procedure as soon as it’s introduced to their practice.

Read on for a full breakdown of the dynamic Vivaer device and how to accurately code for procedures that use it.

Find Out What Vivaer’s All About

The Vivaer device involves the use of controlled radiofrequency energy to shrink submucosal tissue located in the internal nasal airway. Specifically, this procedure may be performed on one or more of the following areas: the nasal valve, the inferior turbinate, and the septal swell body. As Aerin Medical, the developer of Vivaer, explains on its website, enlargement or abnormality of any of these three areas results in a reduction in airflow of the nasal passages. Prior to Vivaer, treatment for nasal obstruction has been typically divided between invasive surgeries utilizing cutting devices, grafting, radiofrequency ablation or coblation techniques, and over-the-counter options such as nasal sprays or breathing strips.

The device itself is a single-patient-use handpiece called a stylus, controlled by an intuitive smart console. Once the stylus is plugged in, the console will automatically set treatment parameters in preparation for the procedure. Using “proprietary algorithms,” the console generates temperature-controlled, bipolar radiofrequency energy via the single-use stylus to reduce or destroy hypertrophied or abnormal submucosal tissue. Additionally, a useful built in sensor on the stylus tip actively monitors and maintains a set temperature to minimize damage to the mucosa.

See How Vivaer Differs From Traditional Radiofrequency Techniques

You may be initially wondering how this procedure is different than your typical inferior turbinate ablation surgery. While the surgeon will perform both of these services in the office, the comparisons between the two end there. That’s because the Vivaer device’s design and temperature-controlled features allow for radiofrequency energy to be delivered to submucosal tissues without an incision, while minimally impacting the mucosal surface. On the other hand, turbinate ablation/coblation therapy typically requires an initial incision into the mucosal tissue in order to apply the radiofrequency energy directly to the submucosal tissue.

As you can imagine, it’s that underlying incision into the mucosal surface and subsequent thermal destruction of submucosal tissue, often combined with out-fracturing of the turbinates, that makes traditional radiofrequency ablation surgery so invasive. On the other hand, Vivaer introduces a technique that results in a substantially easier radiofrequency treatment. The same idea applies to treatment of stenosis and a swollen upper nasal valve or septal swell body (abnormal tissue on the septum).

“Physicians are always looking for new and modified surgical techniques that ease the burden of the patient,” says Kimberly Quinlan, CPC, senior medical records coder for the University of Rochester Medical Center’s Department of Otolaryngology in Rochester, New York. “The Vivaer procedure is certainly an appealing alternative to its more invasive radiofrequency ablation counterpart,” Quinlan explains.

Code Accordingly For Each Respective Site

Now that you’ve got a feel for what the Vivaer procedure entails, you’ll want to make sure you’ve got the coding logistics down pat. For treatment of the septal swell body, you’ve got to consider the underlying cause of the swelling. Hypertrophy of the septal swell body is caused by the formation of abnormal tissue around the septum that widens the septum and reduces airflow through the nasal cavity.

Based on the abnormal tissue etiology, the most appropriate code to report for Vivaer performed on the septal swell body is 30117 (Excision or destruction (eg, laser), intranasal lesion; internal approach). Since 30117 has a bilateral surgery indicator of “0,” you may not bill for it using bilateral modifiers. Rather, if the surgery is performed on both the right and left septal swell bodies, you should append modifier XS (Separate structure, a service that is distinct because it was performed on a separate organ/structure) or 59 (Distinct Procedural Service), depending on payer preference. The diagnosis for swell bodies on the septum is J34.89 (Other specified disorders of nose and nasal sinuses).

Go Unlisted for Nasal Valve Reduction

Next, you’ll want to make the proper coding considerations for Vivaer radiofrequency treatment of the upper nasal valve. Since there are no existing codes that accurately detail the work performed in a Vivaer upper nasal valve reduction technique, your best option is to report the service with the unlisted code 30999 (Unlisted procedure, nose).

“You may equate the service to operating room [OR]-based code 30465 [Repair of nasal vestibular stenosis (eg, spreader grafting, lateral nasal wall reconstruction)] in box 19 of your CMS 1500 form,” advises Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, AAPC Fellow, of CRN Healthcare in Tinton Falls, New Jersey. “Additionally, if you’re negotiating with the payer or submitting an appeal, emphasize that by utilizing the Vivaer approach, you’re saving the patient significant stress not only by avoiding anesthesia within the OR, but also saving the insurance company anesthesia and facility fees,” explains Cobuzzi. You would also use J34.89 (Other specified disorders of nose and nasal sinuses) as your diagnosis when coding for the nasal vestibular stenosis.

Report 30801 for Inferior Turbinates

Finally, you’ll want to know how to report Vivaer radiofrequency when performed on the inferior turbinate(s) to reduce the turbinate hypertrophy submucosally. Essentially, you can look at Vivaer as performing the work of 30801 (Ablation, soft tissue of inferior turbinates, unilateral or bilateral, any method (eg, electrocautery, radiofrequency ablation, or tissue volume reduction); superficial) while having the effect of 30802 (Ablation, soft tissue of inferior turbinates, unilateral or bilateral, any method (eg, electrocautery, radiofrequency ablation, or tissue volume reduction); intramural (ie, submucosal)). Even though the hypertrophy is reduced submucosally, you will not report 30802 since no incision is made to access the submucosal tissue. Therefore, you should report 30801 when the inferior turbinate(s) is treated using the Vivaer device. Since this code is inherently unilateral or bilateral, you should not consider a bilateral modifier when performed bilaterally.

Coder’s note: Most physicians will treat two to three of the respective anatomic sites at the same patient encounter using the Vivaer technique. When the surgeon performs radiofrequency on two or more sites, you should not consider any bundling rules since there are no National Correct Coding Initiative (NCCI, or CCI) edits between 30117 and 30801.