Otolaryngology Coding Alert

Otolaryngologists should not code electrocautery or laser ablation of turbinates as a turbinate resection because it will cause loss of reimbursement by adding a 90-day global period. Not only is the turbinate resection code incorrect in this instance, but the 90-day global period means that any follow-up with the patient will not be reimbursed, says Barbara Cobuzzi, MBA, CPC, CHBME, president of Cash Flow Solutions, a physician reimbursement consulting firm in Lakewood, NJ.

Some otolaryngologists insist on documenting the procedure as a resection, so coders need to carefully read the entire operative report to determine what actually occurred so they can bill it accurately.

Resection/Excision vs. Destruction/Ablation/Cauterization

Although both procedures involve the removal of turbinate bone, they differ clinically and vary significantly in terms of reimbursement, Cobuzzi says. When turbinates are electrocauterized or ablated with a laser, they are destroyed, which means nothing will be sent to a pathology lab. When turbinates are excised, or resected, whatever was removed goes to pathology for analysis. Some otolaryngologists, however, still refer to the destruction of turbinates in their operative reports as a resection because the turbinate or a section of it is no more.

Many otolaryngologists perform either electrocautery or laser ablation of turbinates in their own offices. The procedure usually is performed when a diagnosis by CT scan shows nasal obstruction caused mainly by turbinate hypertrophy (478.0). The physician either may electrocauterize the turbinate or ablate it with a laser. The procedure, which should be coded 30802, is performed to remove excessive mucosa from the turbinates. The physician also may use a diagnostic scope to pinpoint the exact location of the section that is to be destroyed.

Although some otolaryngologists may be tempted to bill this procedure as a turbinate resection, Medicare requires physicians to code procedures to the highest level of specificity. In the case of electrocautery or laser ablation of turbinates, 30802 (cauterization and/or ablation, mucosa of turbinates, unilateral or bilateral, any method [separate procedure]; intramural) is a much more accurate description of the procedure that actually was performed than 30130 (excision turbinate, partial or complete, any method) or 30140 (submucous resection turbinate, partial or complete, any method). If there is a closer, more appropriate code you need to use it, so even if you argue that the ablation is a resection, its not the most specific code, Cobuzzi says.

Get Reimbursed for Subsequent Visits

Compliance with coding guidelines, however, is not the only reason that otolaryngologists and their staffs should use 30802 correctly when they cauterize or ablate turbinates. The procedure, which is considered relatively minor surgery, has a 10-day global period, while the global period for 30130 (excision turbinate) is 90 days.

Therefore, even though 30130 initially reimburses higher (5.32 relative value units [RVUs], according to Medicares 1999 National Physician Fee Schedule Relative Value Guide) than 30802 (3.14 RVUs), coding the destruction of turbinates with 30130 forfeits the opportunity to bill for any patient follow-up visits for 90 days.

Patients usually return to the doctor approximately two weeks after the procedure so that the physician can see how they are doing, Cobuzzi says. Because 30802s global period is only 10 days, otolaryngologists will be reimbursed for the follow-up visit and for any other related work they do that falls outside the shorter
10-day period.

Code 30802 also reduces the amount of paperwork for otolaryngologists, says Stella Almassian, the administrator of the Department of Otolaryngology at Northwestern University in Chicago, IL. If the physician codes the turbinate ablation as 30130 and the patient has a follow-up procedure within the 90-day global period for example, because of a complicationthe otolaryngologist needs to document why an insurance carrier should reimburse separately for the follow-up preocedure. But if the otolaryngologist uses 30802, the global period is shorter, and the follow-up services likely will fall outside that period.

Coding Before, During and After Ablation

One typical coding scenario involving ablation/cauterization of turbinates begins with a new patient visiting the otolaryngologist and reporting nasal congestion and headaches. The physician evaluates the patient (9920x, depending on the level of evaluation and management [E/M] provided) and performs a diagnostic scope (31231, nasal endoscopy, diagnostic, unilateral or bilateral [separate procedure]). The code for the separate E/M service should have modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) attached.

Note: If the physician just uses the scope, the E/M service should not be billed. But this probably would not be the case for a new patient.

During the course of the examination, the physician notices that turbinates are obstructing the sinuses. The patient is sent for a CT scan to determine if sinus disease is contributing to his or her symptoms.

But the results of the CT scan rule out sinus disease, and the physician decides that laser ablation is the best treatment for the condition. During a separate office visit, the otolaryngologist explains to the patient how the procedure works, and the patient agrees to return in two weeks for the procedure. This office visit would be coded 9921x, again depending on the level of E/M service provided.

When the patient returns for the procedure, no E/M service may be billed unless something significant in the patients condition has changed. Minimal E/M is performed before the procedure. The otolaryngologist scopes the patient to determine precisely where and what needs to be done with the laser. He or she then ablates the turbinates (30802). The turbinate bones are destroyed, and nothing has been removed for pathology.

Although the physician used the endoscope, he may not bill for it because procedures that are performed for determining placement or aiding in performing the primary procedure (i.e., using the scope to see where youre working) always are considered part of the primary procedure. You cant bill for a scope when it is used just to help you find the turbinate, Almassian explains.

Two weeks later, the patient returns for a follow-up exam. The otolaryngologist reviews the patients progress and makes an adjustment to the patients medication. This visit also would be billed 9921x, depending on the level of E/M service provided.

Coders should educate their otolaryngologists so that the beginning of the operative report matches the procedure they actually describe. Coders need to look beyond the obvious, Cobuzzi says. Even if youre used to using 30130 and 30140 for turbinates, you cant just make assumptions. You have to go to the book [CPT 2000] and find the closest code for what you did.