Otolaryngology Coding Alert

To avoid payers 'thinking that your otolaryngologist performed an inferior turbinectomy to access the sinuses, the operative report and the office notes need to show the medical necessity for each procedure.

Because many claims for turbinate removal and sinus procedures will ultimately require appeals and submitting chart and surgical notes, laying the initial groundwork with the office notes will allow the payer to follow the medical necessity from the beginning steps to the surgical procedure. Carriers increasingly want the office notes, not just the operative report, to justify why the patient needs the inferior turbinate removed (30130-30140), as well as the ethmoidectomy (31254-31255), says Teresa M. Thompson, BS, CPC, an ENTcoding specialist and the owner of TM Consulting in Sequim, Wash.

Consequently, an entry should include the patient's complaint, which explains why the patient needs the service. In essence, carriers want to see office notes that say, "This is what we need to do, this is why we need to do it, and therefore we are going to go ahead and do the procedure," Thompson says.

The operative notes must continue this trend toward documenting why the patient needs surgical intervention."The op note should be as specific as possible," Thompson says.

For example, the otolaryngologist may start with initial diagnoses of pansinusitis (473.8, Chronic sinusitis; other chronic sinusitis) and airway obstruction (such as, 519.8, Other diseases of respiratory system, not elsewhere classified). By the time the surgeon finishes his operative note, he should identify the reasons for airway obstruction, which sinuses need to be worked on, and why the surgery was done on each particular sinus cavity.

Knowing these details will help you to report the most specific diagnosis, including coding to the fourth or fifth digits, if necessary.

You must break down each procedure and link it to the appropriate diagnosis, says James N. Palmer, MD, assistant professor of the division of rhinology at the University of Pennsylvania in Philadelphia. When you bill turbinectomies and ethmoidectomies, a diagnosis of nasal obstruction must support 30130-30140, and an ethmoid diagnosis must support 31254-31255, he says. For instance, a patient has chronic ethmoid sinusitis (473.2, ethmoidal), which the surgeon treats with removal of the left anterior ethmoid. In addition, the patient has hypertrophy of nasal turbinates (478.0), so the otolaryn-gologist excises the left inferior turbinate. You should link the partial ethmoidectomy (31254-LT) to 473.2, and the turbinectomy (30130-59-LT) to 478.0.

Correct linkages will alert the payer that the physician operated on each sinus out of medical necessity, not to gain access to the ethmoid.