Otolaryngology Coding Alert

Some local Medicare carriers are bundling inferior turbinectomies with ethmoidectomies, and coding specialists recommend that if denied, they should be appealed vigorously and reported to the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) whenever they occur.

Even so, until physician groups like the American Medical Association (AMA) and the AAO-HNS can reverse the bundle, attributed by most coding specialists to a black box edit, not all appeals may be successful. One strategy that may be useful in obtaining reimbursement if your Medicare carrier inappropriately is bundling inferior turbinates to ethmoidectomies is to attach modifier -59 (distinct procedural service) to the turbinate removal code.

The edit is believed to be part of a commercial software package similar to GMIS ClaimCheck developed by Atlanta-based HBO&C, which is proprietary and therefore has not been published. Providers can only reason by experience which procedures will not be paid if the edit originates in this so-called black box.

Turbinate Removal Codes

To complicate matters, CPT does not differentiate in its coding between the inferior and middle turbinates. There are three principal turbinate removal codes:

30130 excision turbinate, partial or complete, any method;

30140 submucous resection turbinate, partial or complete, any method; and

30802 cauterization and/or ablation, mucosa of turbinates, unilateral or bilateral, any method (separate procedure) intramural.

These codes are not bundled to 31254 (nasal/sinus endoscopy, surgical; with ethmoid-ectomy, partial [anterior]) and 31255 (nasal/sinus endoscopy, surgical; with ethmoidectomy, total [anterior and posterior]) in Medicares Correct Coding Initiative (CCI).

Until now, there seemed to be an unwritten understanding that the removal of middle turbinates, which is part of the ethmoid complex, was incidental and shouldnt be billed separately when an ethmoidectomy was performed. Inferior turbinates, however, are a different matter. They routinely are not removed during ethmoidectomies, and when they are removed, the reason is not for access, but rather to improve the airway.

If a patient has large turbinates due to an allergy or a large turbinate bone, the size of the turbinate sometimes has to be reduced to improve the airway. For example, if a patient has a right septal dislocation that is obstructed totally, the body, over time, tends to reduce airway size on the left, and the inferior turbinate on the left is likely to enlarge. If a septoplasty (30520, septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft) is performed to move the septum and the size of the enlarged turbinate isnt reduced, the patient likely will have an obstruction in the left nostril.

Therefore, codes 30130, 30140 and 30802 always have been payable separately when performed during the same session as an ethmoidectomy or septoplasty, as long as the inferior turbinates were removed.

Note: There is one exception to the middle turbinate edit. If the patient has a septoplasty and inferior turbinates are removed, and he or she also requires endoscopic removal of a large middle turbinate (known as a concha bullosa), the removal of the concha bullosa may be billed separately using code 31240 (nasal/sinus endoscopy, surgical; with concha bullosa resection).

Inferior turbinate denials are carrier specific, notes Teresa Thompson, CPC, an independent otolaryngology coding and reimbursement specialist in Sequim, Wash. She adds that for some carriers, the method used to remove the turbinates also determines if the claim will be paid.

A few carriers are denying all three codes, but others are denying 30130 only, she says. Some carriers dont want to pay for ablation or outfracture (crushing the turbinate), but if an excision (30130 or 30140) is performed, it may be reimbursed. Cautery of turbinates (30802) is bundled more than resection of turbinates (30140) because it is more complex and because it is categorized as a separate procedure, even when inferior turbinates are involved.

Use Modifier -59 to Indicate Different Site

Using modifier -59 informs the carrier that the inferior turbinates are on a different site than the ethmoid sinuses. Middle turbinates would be considered on the same site; consequently their removal is incidental.

Before some Medicare carriers began bundling inferior turbinate removal with ethmoidectomy, modifier
-59 was unnecessary and did not apply because the procedures were not bundled in the CCI. Although the edit still is not in the CCI, modifier -59 now does apply if your carrier is bundling the two procedures. The relationship between the ethmoidectomy and the inferior turbinate removal provides a great example of how modifier -59 works. Because removal of middle turbinates are incidental in an ethmoidectomy, they are bundled, (remember, theres only one code for both middle and inferior turbinates), but if the same procedure is performed at a different site, then modifier -59 is supposed to override the edit. The inferior turbinates occupy this type of different site. Because modifier -59 was designed for CCI edits, but some Medicare carriers are employing the black box edit, the modifier may not improve the chance for payment.

Otolaryngologists also should note better in their documentation why the inferior turbinate(s) had to be removed, Thompson says. With some carriers, if the documentation were better, otolaryngologists at least would get paid on appeal.

A second diagnosis, such as hypertrophy of turbinates (478.0), should be used (when appropriate) to bolster the case for payment for the turbinate removal because it indicates the procedure is being performed for a different reason in addition to being done on a different site.

Locate Carriers Local Medicare Review Policy

The AAO-HNS has confirmed many instances of this sort of inappropriate bundling. According to George Roman, the academys director of practice management, inferior turbinates arent bundled with ethmoidectomies in the CCI or any authoritative coding manual.

If the local Medicare carrier is bundling these two procedures, Roman advises healthcare providers to:

Get a copy of the carriers local medical review
policy;

Advise the state medical association about the situation;
and

Contact the carrier advisory committee and the
medical director. All Medicare carriers have advisory committees, which are represented by all specialties,
including otolaryngology. The otolaryngology representative should be contacted and urged to
reconsider the policy. The issue also should be appealed to the carriers medical director.

Note: Some practices already have appealed unsuccessfully such denials to the first level in which the carrier evaluates the appeal. The appeals are now at the fair hearing level, which is a review performed by inde-pendent officers with no carrier affiliation. Otolaryngology Coding Alert will report new developments as they arise.