Otolaryngology Coding Alert

Otolaryngologists often treat obstructive sleep apnea by performing a uvulopalatopharyngoplasty (UPPP), but face denials when they bill for the procedure. By vigorously appealing these denials with supporting documentation, physicians can ensure proper reimbursement.

UPPP (42145, palatopharyngoplasty, e.g., uvulopalatopharyngoplasty, uvulopharyngoplasty) is performed for a variety of reasons, most commonly snoring (786.09, dyspnea and respiratory abnormalities, other); upper airway resistance syndrome (780.56, dysfunctions associated with sleep stages or arousal from sleep) and/or obstructive sleep apnea (780.57, other and unspecified sleep apnea). The procedure also may be performed on patients with malignant lesions of the hard or soft palate or uvula (145.2, malignant neoplasm of other and unspecified parts of the mouth, hard palate; 145.3, soft palate; 145.4, uvula; 145.5, palate, unspecified, junction of hard and soft palate, roof of mouth) or benign lesions (210.4, benign neoplasm, palate [hard], [soft], uvula).

UPPP involves removing elongated and excessive tissues of the uvula, soft palate and pharynx. Incisions are made in the soft palate mucosa, and a wedge of mucosa is excised. Excessive submucosal tissue is then removed, and the uvula is excised. After the midline of the uvula is sutured, the otolaryngologist closes the remaining mucosa in a single layer, which increases the diameter of the oropharynx.

UPPPs and Tonsillectomies

When performing this procedure, the otolaryngologist often will perform a tonsillectomy because the tonsils are hypertrophied or inflamed or because the patient has chronic tonsillitis. Healthy tonsils typically are not removed during a UPPP.

Many commercial carriers routinely deny tonsillectomy claims when performed with UPPP, stating the tonsil removal is incidental to the primary procedure. These denials should be appealed vigorously, coding experts say. And an important weapon in the appeals arsenal should be letters and policy statements from professional societies such as the American Medical Association (AMA) and the American Academy of Otolaryngologists-Head and Neck Surgery (AAO-HNS) that support the otolaryngologists position.

The professional societies blame the software commercial carriers use for what they consider inappropriate bundling. Many medical carriers are utilizing software packages that rebundle CPT codes. One of the more common practices is to deny the payment for tonsillectomy when done in conjunction with UPPP on the basis that they are performed through the same incision, says Michael D. Maves, MD, MBA, immediate past executive vice president of AAO-HNS. Maves calls the bundling of these two procedures an arbitrary and capricious decision on the part of the medical carrier.

According to an AAO-HNS policy statement, A tonsillectomy and UPPP are separate and distinct surgical procedures. Each requires the application of distinct surgical skills and judgment to separate anatomic sites. Each of these surgeries entails separate surgical risks. When done together, each procedure would be (1) identified by its distinct CPT code, and (2) billed and reimbursed accordingly.

The AMA concurs. According to the AMAs CPT Information Service, If a tonsillectomy (as indicated by codes 42821 (tonsillectomy and adenoidectomy, age 12 or over) or 42826 (tonsillectomy, primary or secondary; age 12 or over) is performed during the same session as a uvu-lopalatopharyngoplasty (42145), then it would be appropri-ate to report the two services with separate codes. The tonsillectomy is considered a separate procedure from the 42145 procedure, and, therefore, both services should be reported.

Ann Hughes, a coder in the office of Mid-Vermont ENT in Rutland, Vt., says these policy statements should be included when appealing the denial of tonsillectomy performed in conjunction with UPPP. When we quote letters and policy positions from the AMA and AAO-HNS, I get 90 percent reversal of denials, Hughes says.

Medicare Likely to Deny LAUP and Somnoplasty

Although Medicare carriers do not bundle tonsillectomies and UPPP like many private carriers, they will not cover laser-assisted uvulopalatoplasty (LAUP) or somnoplasty. But some private carriers do cover these procedures under certain conditions.

LAUP and somnoplasty differ from UPPP in significant ways. The laser procedure, for example, excises only part of the uvula and associated soft-palate tissues and does not remove or alter tonsils or lateral pharyngeal-wall tissues. Consequently, many otolaryngologists perform UPPP on patients who also have tonsillar hypertrophy and LAUP on those who do not.

The same holds true for somnoplasty, which treats snoring and mild obstructive sleep apnea by shrinking soft tissues in the upper airway, including the base of the tongue. The procedure uses a low-power, low-temperature radiofrequency energy that treats a confined area in the soft palate and uvula at the back of the mouth. Somnoplasty is an outpatient procedure, accomplished with a local anesthetic. For six weeks after the treatment, the treated areas shrink and excess loose tissue is removed naturally by the body. The tightening and stiffening of these tissues reduces snoring and opens the airway to increase airflow. The somnoplasty procedure may have to be repeated, depending on the severity of the patients condition.

Like LAUP, somnoplasty has not been shown to be an effective treatment for obstructive sleep apnea. Consequently, most Medicare carriers will not reimburse either procedure because they consider them cosmetic. According to policy statements issued by several Medicare carriers, It is inappropriate to report LAUP under procedure code 42145. Use 42299 (unlisted procedure, palate, uvula) to report a LAUP.

Otolaryngologists should note that the procedure likely will not be reimbursed by Medicare, so make sure your Medicare patients sign a waiver before proceeding with the service. If an LAUP is performed and the advance beneficiary notice (ABN) is signed, 42299 should be billed with a -GA modifier (waiver of liability statement on file) to tell Medicare that the ABN is signed and on file, says Barbara J. Cobuzzi, MBA, CPC, a coding and reimbursement specialist in Lakewood, N.J. This ensures that the explanation of benefits (EOB) that goes to the patient indicates that the otolaryngologist is allowed to bill the patient for the procedure.

Private carriers may pay for the procedures, however, so check with your carrier to determine if the planned procedure is covered and then make sure it is precertified. Also, when billing private carriers for LAUP or somnoplasty, otolaryngologists should remember that the procedure, not the method or tools that were used, is the determining factor when choosing the code. Regardless of whether LAUP, somnoplasty or UPPP is performed, the coding remains the same. Because laser and somnoplasty treatments are applied only to the palate and not the pharynx, however, the procedure is considered a uvulopalatoplasty. Therefore, these services should be coded with modifier -52 (reduced services) appended to the 42145, Hughes says, noting that the literature on LAUP specifically indicates that the complete uvulopalatopharyngoplasty has not been performed.