Otolaryngology Coding Alert

Fight private payers that contradict Medicare rules and deny follow-up services for FESS with a ready-to-go appeals letter.

Medicare grants zero-day global periods to all functional endoscopic sinus surgery (FESS) codes (31237-31288). The relative value units awarded to these codes are for the sinus surgery only and do not include postoperative care. But some commercial payers erroneously bundle postprocedure services, such as office visits (99211-99215-25, Office visit for an established patient; significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service), endoscopies (31231-31235) and debridement (31237, Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement [separate procedure]), with the FESS code. You should appeal these denials.

To make winning an appeal easier, encourage your otolaryngologist to write a clean note when he or she performs these procedures, says Barbara Cobuzzi, MBA, CPC, CPC-H, president of Cash Flow Solutions, a medical billing firm in Lakewood, N.J. The physician should include separate paragraphs for the office visit, the debridement and endoscopy. Aclean, detailed chart note should show the payer that a significant, separately identifiable E/M service occurred in addition to the procedure. Send the report with an appeal letter.

To get you started, Cobuzzi created a letter to appeal post-FESS office visit and debridement bundling. Use the letter only for a patient who did not have a scheduled debridement and the physician, based on the visit, decided that the patient needed a debridement. If the doctor scheduled the patient for a debridement, you should not bill an E/M and appeal only 31237. If the otolaryngologist also performed a turbinectomy or septoplasty, which have larger global periods, with the FESS, use a different letter.

Dear Insurance Company,

This letter appeals the nonpayment of medical services following endoscopic sinus surgery for patient Icant Breathe on March 10, 2003.Endoscopic sinus procedures that were performed on Mr. Breathe on March 5 carry a global period of zero days, which means that all services following the surgery are payable.The reimbursement for endoscopic sinus surgery is priced lower, taking into account that these procedures have zero global days and that the surgeon can charge for all services following the surgery.

An office visit and sinus debridement were performed on the date of service in question, 3/10/03. Mr. Breathe was evaluated, and it was determined that it would be appropriate and beneficial to do a sinus debridement on conclusion of the office visit. As you can see from the enclosed notes from 3/10/03, a history, exam and medical decision-making independent from the debridement were performed and documented. Thus, the office visit (99212-25) and the sinus debridement (31237) are both payable for 3/10/03.

Please do not hesitate to contact me if you have any questions. I can be reached at (555) 555-5555. We expect payment for these services immediately because the initial denial has delayed monies earned and deserved by the doctor. Further hold up of doctor's rightful payment will be reported to the state Department of Insurance as well as the state medical society where they keep tabs and totals on inappropriate delays in payments by third-party payers. Please remember the future that zero-global-day procedures like endoscopic sinus surgeries entitle the doctor to immediate payment for all services after the surgery consistent with the meaning of the global package. Thank you for your assistance.