Otolaryngology Coding Alert

Be careful: Regular sinus codes don't capture the new technology's work, AAO-HNS warns
 
To protect functional endoscopic sinus surgery (FESS) code values, you have to use an unlisted-procedure code for sinus surgery using a balloon catheter.

Avoid Manufacturer's -Recommendations-

It's a good rule of thumb not to rely on billing advice from equipment vendors. And balloon sinuplasty coding is no exception.

Some coders and otolaryngologists heed what they interpret as the balloon sinuplasty manufacturer's recommendations and use the regular sinus codes based on the site. But coding guidelines and the American Academy of Otolaryngology -- Head and Neck Surgery (AAO-HNS) don't support this practice.

Misleading: The balloon sinuplasty manufacturer's (Acclarent) Web site indicates that hospital outpatient departments and physicians commonly bill site-specific endoscopic sinus codes for the balloon sinuplasty procedures. Providers should -select the appropriate codes and modifiers that reflect the services furnished to individual patients and follow specific payers- coding and billing instructions,- according to the Web site. Inappropriate codes the vendor listed include:

- 31254 -- Nasal/sinus endoscopy, surgical; with ethmoidectomy, partial (anterior)

- 31256 -- Nasal/sinus endoscopy, surgical, with maxillary antrostomy

- 31276 -- Nasal/sinus endoscopy, surgical, with frontal sinus exploration, with or without removal of tissue from frontal sinus

- 31287 -- Nasal/sinus endoscopy, surgical, with sphenoidotomy

- +61795 -- Stereotactic computer-assisted volumetric (navigational) procedure, intracranial, extracranial or spinal (list separately in addition to code for primary procedure).

Don't overlook: The company does warn that this list is based only on codes used for balloon sinuplasty and not on accepted policy. -The information does not constitute reimbursement or legal advice or advice about how to code for procedures,- the company stipulates. Further, the company says, -It is the provider's responsibility to determine and submit appropriate billing codes and charges that best describe the services furnished to a particular patient.-
 
Realize Balloon Sinuplasty, FESS Codes Don't Match

The AAO-HNS interprets the balloon sinuplasty manufacturer's caveat as an indication that no specific CPT code exists for this new technology. In addition, -the Academy has not received a formal request from the manufacturer supporting use of approved CPT codes for FESS procedures using the balloon sinuplasty technology,- according to the AAO-HNS bulletin on the device.

Instead: The Academy recommends not using 31254-31287. -The sinuplasty procedure differs materially from the vignettes for the original endoscopic surgery codes,- states the article Task Force Formed to Review Balloon Sinuplasty Procedure.

Linguistically, reporting balloon sinuplasty with some FESS codes doesn't make sense. Here's why:

Reason 1: Codes 31254-31287 describe sinus endoscopy. -To bill regular FESS codes, your otolaryngologist needs to use an endoscope,- says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC, president of CRN Healthcare Solutions in Tinton Falls, N.J.

In balloon sinuplasty, the physician threads a guidewire equipped with a balloon into the nostrils and up into the blockage, as described in BlueCross BlueShield of Tennessee's policy on the new technology. Using this catheter-based inflatable device differs from endoscopic sinus surgery, which involves using a fiberoptic nasal endoscope to visualize the sinus ostia and correct any obstruction found.

Reason 2: Some FESS codes also require a surgical portion that balloon sinuplasty avoids. -Ethmoidectomy has the suffix -ectomy,- which means to cut out,- Cobuzzi says. But a sinus balloon catheter dilates the blocked sinus opening without removing tissue or bone, according to the device's literature. So 31254 would not appropriately describe balloon sinuplasty of the ethmoid.

Protect 31254-31287 Values by Using 31299

You should instead report the balloon sinuplasty procedure with 31299 (Unlisted procedure, accessory sinuses). This AAO-HNS coding recommendation -is consistent with the process required of all other specialties reviewing new technologies.-

Using 31299 rather than 31254-31287 will also prevent future reduction of FESS code values. -If physicians continue to use existing sinus surgery CPT codes for the balloon sinuplasty procedure, this could have a deleterious impact, eroding credibility in coding for sinus procedures, creating controversy on work values, and skewing the statistics on utilization,- the Academy says.

Not over: The Academy appointed a task force chaired by David Kennedy, MD, to review several issues surrounding the procedure including its coding. For more information, visit http://www.entlink.net/press/bulletin/Balloon.cfm.

Describe Hybrid Procedure With FESS Codes

Some otolaryngologists use a balloon catheter as part of a hybrid procedure that warrants FESS codes. -When balloon sinuplasty is done in combination with traditional functional endoscopic surgery tools, FESS codes are appropriate,- says Michael Setzen, MD, FACS, FAAP, chief of rhinology at North Shore Otolaryngology Associates in Manhasset, N.Y.

Important: Setzen bases his coding on the Academy's recommendations. The balloon sinuplasty article prompted Setzen to pose the question as to coding for combination FESS with balloon sinuplasty. The Academy answered in an editorial letter that in these cases traditional FESS codes would be fine to use.

Catheter as nontraditional endoscopic tool: The procedure that Setzen asked for coding advice on described -performing an endoscopic frontal sinusostomy by removing bone and polypoid tissue separating the floor of the frontal sinus from the frontal recess of the ethmoid. The procedure was performed under endoscopic visualization with giraffe forceps and powered microdebrider. At the conclusion of the operation, a sinus balloon catheter was placed into the sinusostomy to widen it further and remove bone spicules.-

AAO answer: You should code this case with 31276 (Nasal/sinus endoscopy, surgical with frontal sinus exploration, with or without removal of tissue from frontal sinus), according to the Academy's response. -All components of the standard endoscopic sinusostomy have been performed with the only addition being use of a balloon catheter to complement the forceps and microdebrider,- writes Linda Taliaferro, director of regulatory and socioeconomic affairs for the AAO-HNS in -Letter to the Editor: Balloon Sinuplasty- published in the Bulletin.

Key: If the balloon catheter is used to facilitate creation of a frontal sinusostomy using a technique different from the standard surgical approach, such as using fluoroscopy for catheter guidance, you should instead report the procedure as 31299, Taliaferro says. The fluoroscopy, which could take up to an hour of physician time, would be coded with 76000-26 (Fluoroscopy [separate procedure], up to one hour physician time, other than 71023 or 71034 [e.g., cardiac fluoroscopy]; Professional component), Setzen adds.

Look for Policies That Echo AAO-HNS Advice

Because balloon sinuplasty is so new (the Federal Drug Administration approved Acclarent's Balloon Sinuplasty System in 2005), check with your insurer for guidelines. Some companies have released new or revised balloon sinuplasty policies this fall.

Most policies disallow coverage. BlueCross BlueShield of Tennessee considers -balloon sinuplasty for the treatment of chronic sinusitis- investigational. National Heritage Insurance Company (NHIC) (Medicare Part B carrier for Northern California) also deems the procedure investigational and not covered in its draft policy last reviewed on Sept. 13, 2006.

Both NHIC and The Regence Group (TRG) (Blue Cross and/or Blue Shield Plans serving Idaho, Oregon, Utah, Washington) follow the AAO-HNS's coding guidelines. TRG's medical policy approved Aug. 8, 2006, gives clear guidance: -There is no CPT code that specifically describes the use of the sinus balloon dilatation device. It is not appropriate to code this procedure using the nasal/sinus endoscopy codes 31231 through 31294. Instead, the procedure should be coded using the unlisted sinus procedure code 31299 to represent balloon sinuplasty.-