Otolaryngology Coding Alert

Experts reveal how you can stop those 42145 denials

Trying to receive payment for uvulopalatopharyngoplasty (UPPP) can make you feel as if you're the one with a sleep disorder. Because payers have stringent requirements for 42145 coverage, patients who don't meet the medical-necessity criteria can leave your ENT footing the bill.

You probably know that payers won't cover 42145 (Palatopharyngoplasty [e.g., uvulopalatopharyngoplasty, uvulopharyngoplasty]) without a sleep study, but some payers deny UPPP payment even with the study requirement, says Lorin Easly, billing manager at Central Oregon Ear, Nose, Throat, Head and Neck Surgery, a five-otolaryn-gologist practice in Bend, Oregon. "I used to work in Portland for a sleep-disorder specialist and never had any problems getting paid for 42145," she says. But at her new practice, insurers deny 42145 coverage for lack of medical necessity.

Don't give up, says Darlene Reed, CPC, certified coder for Northland Ear, Nose and Throat in Liberty, Mo. Get a predetermination before your otolaryngologist performs each UPPP procedure. That way, if the patient doesn't meet the payer's requirements, you can charge the patient for 42145.

Coding experts offer three tips for improving your UPPP reimbursement:

A sleep study is insufficient reason to support a UPPP. The sleep-disorders laboratory must diagnose the patient with obstruction sleep apnea (780.51, Sleep disturbances; insomnia with sleep apnea; 780.53, ... hypersomnia with sleep apnea; or 780.57, ... other and unspecified sleep apnea), Reed says.

"Medicare's rules for an OSA diagnosis are pretty stringent," Reed says. The polysomnography must show that the patient has at least 30 episodes of apnea per hour, she says. In addition, the patient must have an apnea-hypopnea index (AHI) greater than 15 events per hour, or AHI between six and 13 events per hour with documented symptoms of excessive daytime sleepiness, impaired cognition, mood disorders or insomnia, or documented hypertension, ischemic heart disease or history of stroke.

Plus, the patient's record must show that the patient failed to respond to continuous positive airway pressure (CPAP) therapy or cannot tolerate CPAP or other appropriate noninvasive treatment, she adds.

Easly's 42145 denials, however, are from private payers, not Medicare. To get third-party payers to cover 42145, you should contact each insurer for its sleep-study guidelines, Reed says.

If a patient is close to Medicare's requirements, have your otolaryngologist write a letter of medical necessity to support a UPPP. Send that information along with the precertification information, Reed says.

"I obtain a predetermination for every UPPP, even for payers who don't require it," Reed says. She collects the above information - sleep-study results, CPAP failure documentation, medical-necessity letter, if necessary -and sends these materials to the insurer with a precertifi-cation request for 42145, she says.

Although filing the extra paperwork may seem time-consuming, the work pays off. "We get very few denials," Reed says.

If an insurer denies precertification, treat UPPP as a noncovered, cash procedure. Explain to the patient that his payer will not cover 42145 for noncovered, not medically necessary reasons, so he is responsible for the bill, Reed says. Make sure you emphasize that even though CPAP may cause visible signs, such as strap marks, noncoverage applies to UPPP, she says.

Have the patient sign a private insurance equivalent of an advance beneficiary notice and pay cash up-front for the procedure. Otherwise, your otolaryngologist will get stuck with the bill.