Otolaryngology Coding Alert

Most ENT's are giving it away, but here's why you can bill 31240 separately

If you now bundle concha bullosa resection into ethmoidectomy or maxillary antrostomy, there's a new paper from a University of Pennsylvania researcher who says your otolaryngologist is losing $85 per procedure.

Add 1 Turb Procedure to FESS-Also Bill

The February 2007 Otolaryngology Coding Alert listed three times when middle turbinate work is not considered access and is thus billable. -There is one other exception for coding middle turbinate surgery, and that is if it is a concha bullosa endoscopic resection (31240, Nasal/sinus endoscopy, surgical; with concha bullosa resection),- says Sanford M. Archer, MD, FACS, associate professor of surgery, Division of Otolaryngology-Head and Neck Surgery at the University of Kentucky Medical Center in Lexington.

-I do not usually include the concha bullosa resection (31240) with the middle turbinate excision/submucous resection scenarios- that are coded to 30999 (Unlisted procedure, nose), says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J. Why: The 30999 procedures are open, and 31240 is an endoscope procedure.

Truth: You can separately bill endoscopic resection of concha bullosa of the middle turbinate (31240) that the otolaryngologist performs in addition to ethmoidectomy (31254-31255, Nasal/sinus endoscopy, surgical; with ethmoidectomy -) or antrostomy (31256-31267, Nasal/sinus endoscopy, surgical, with maxillary antrostomy ...).

Separate 31240 Billing Trumps Bundled View

Controversy has historically existed over whether you should bill the resection with ethmoid and/or maxillary sinus surgery. Some surgeons think that because the concha bullosa resection is a minor procedure, it should not be billed separately, Cobuzzi says.

But the scale is now tipping the other way, thanks to an article written by David W. Kennedy, MD, FACS, professor and director, Division of Rhinology, Department of Otorhinolaryngology: Head and Neck Surgery, vice dean for professional services and senior vice president, University of Pennsylvania Health System in Philadelphia. -Appropriate resection of a concha bullosa, with preservation of middle turbinate integrity, and preservation of the mucosa on both sides of the preserved lamella, and resection of areas of exposed bone does indeed create a significant time commitment,- he counters in -Should Excision of Concha Bullosa Be Reimbursed in Addition to That for Endoscopic Surgery?- published by the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS).

Ethmoidectomy (31254-31255, Nasal/sinus endoscopy, surgical; with ethmoidectomy -) codes do not include the work value for concha bullosa resection (31240), says Kennedy, who was involved with the initial AMA relative value update committee valuation of the functional endoscopic sinus surgery (FESS) CPT codes. -The work value for ethmoidectomy does, however, include other forms of middle turbinate resection.-

Action: When an otolaryngologist operates on the ethmoids (31254-31255) and middle turbinates, code based on these bundling rules:

--Separately bill for concha bullosa resection via endoscope (31240)

--Do not bill for middle turbinate excision or submucous resection (both 30999).

Accept Multiple-Procedure Reduction

You shouldn-t, however, expect full payment on 31240 with 31254-31255. -When it's performed in conjunction with ethmoidectomy, the work value for the concha bullosa will reduce by 50 percent,- Kennedy says. If the otolaryngologist performs the endoscopic resection of concha bullosa as a third procedure, some private payers, such as Aetna, could reduce payment for 31240 by 25 percent.

Why: Medicare bases this reduction on multiple- procedure rules. Although CPT designates modifier 51 for -Multiple procedures,- Medicare carriers don't want you to use the modifier. The carrier will apply the adjustment, so you-ll receive $84.13 for 31240 as a second procedure instead of the full national rate of $168.26 using the 2007 National Physician Fee Schedule, which assigns 4.44 transitional facility total relative work value units to 31240 ([4.44 RVUs x 37.8975 conversion factor] x 0.50).