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Otolaryngology Coding Alert

Here's How to Fight for Turbinectomy Payment With Ethmoidectomy

Published on Tue Aug 09, 2005

Use rock-solid documentation, duel diagnoses and modifier 59 - and appeal those denials

Employing some basic tools will help you obtain inferior-turbinectomy reimbursement on claims containing ethmoidectomy.

Otolaryngology coders frequently have to battle denials for turbinate surgery in addition to ethmoid sinus surgery. While the following steps can't guarantee prompt payment, they'll set the claim up for a solid appeal.

Clearly Indicate Which Turbinate You're Billing

Documentation must denote that you're requesting inferior-turbinate payment, not middle-turbinate reimbursement. "Because CPT's turbinectomy code doesn't distinguish between inferior and middle turbinates, insurers have no way of telling from the code what site you're charging," says Barbara J. Cobuzzi, president of CRN Healthcare Solutions in Shrewsbury, N.J.

Most insurers bundle the turbinectomy with the ethmoidectomy and assume that you're claiming a middle-turbinate excision. Companies deny 30130 (Excision turbinate, partial or complete, any method) or 30140 (Submucous resection turbinate, partial or complete, any method) with 31254 (Nasal/sinus endoscopy, surgical; with ethmoidectomy, partial [anterior]) and 31255 (...with ethmoidectomy, total [anterior and posterior]) on the grounds that the otolaryngologist either performs the surgeries through the same excision or excises the turbinate to gain entry to the ethmoid.

You should, however, appeal inferior-turbinate denials using documentation that shows the surgeries as distinct procedures. Encourage the otolaryngologist to back his turbinectomy payment with these operative report specifics:

Tip 1: Describe the separate anatomic areas and surgical sites, says Charles F. Koopmann Jr., MD, MHSA, professor and associate chair at the University of Michigan's department of otolaryngology in Ann Arbor. For instance, a note may identify the turbinate and then state "moving to separate surgical area and site (ethmoid air cells)."

"That way, documentation identifies the turbinectomy and ethmoidectomy as separate," Koopmann says. 

Tip 2: Identify the exact turbinate that he addresses. "If you omit this information, the insurer will assume the operation involves the middle turbinate," Cobuzzi says.

Use 2 Diagnoses for 30130-30140, 31254-31255

The first way to show insurers that an inferior turbinectomy is a distinct procedure from the ethmoidectomy is to report different ICD-9 codes. Separate diagnoses demonstrate that the turbinectomy is for a separate problem - nasal turbinate hypertrophy - and not just to gain access to the ethmoids, says Bertie Lubinsky, coding specialist at Action Medical Billing Service in Irvine, Calif.

Here's how:
 

  • For the turbinectomy (30130-30140), use 478.0 (Hypertrophy of nasal turbinates).
     
  • Link the ethmoidectomy (31254-31255) to 473.2 (Chronic ethmoidal sinusitis).

    Assume insurers will request office notes, as well as the operative report. So make sure documentation supports performing the turbinectomy for breathing problems and the ethmoidectomy for sinusitis.

    Designate 30130-30140 as a Distinct Procedure

    If a payer consistently denies 30130 or 30140 because the system assumes the claim involves the middle turbinate, you should also use modifier 59 (Distinct procedural service). Modifier 59 indicates that the turbinectomy is a distinct procedure from the ethmoidectomy. Inferior turbinectomy and ethmoidectomy, unlike middle turbinectomy and ethmoidectomy, occur on a different site from the middle turbinate. Because insurers bundle 30130-30140 with 31254-31255 and circumstances override the edit, you should append modifier 59 to the lesser-valued procedure - the inferior turbinectomy (30130-59 or 30140-59).

    How it works: Modifier 59 tells the insurer that you're billing for a different procedure than the surgery (30130-30140) the insurer normally considers integral to ethmoidectomy (31254-31255). "You're asking the payer to give you payment for the inferior turbinectomy, not the middle turbinectomy," Cobuzzi says.

    Remember: With inferior turbinectomy and ethmoidectomy, you need modifier 59 based on private- payer bundles, not due to Medicare edits. The National Correct Coding Initiative does not impose an edit on 30130-30140 and 31254-31255.

    Appeal, Appeal, Appeal

    If an insurer denies inferior-turbinectomy payment on a claim containing ethmoidectomy, take the time to appeal the decision. Use a form letter to save time. Include the American Association of Otolaryngology-Head and Neck Surgery's Practice Management Department in your fight, if necessary. "Don't let insurers get away with not paying," Cobuzzi says.

    Good news: Your effort may pay off. "We appeal the non-payment of the turbinectomies if not paid, and usually get paid on our appeal," Lubinsky says.

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