Otolaryngology Coding Alert

Are you one of the many coders who have had trouble with payers that deny endoscopic resection of concha bullosa of the middle turbinate when you report functional sinus endoscopy of the ethmoid or maxillary sinuses with an ethmoidectomy?

Even though the Correct Coding Initiative doesn't bundle 31240 (Nasal/sinus endoscopy, surgical; with concha bullosa resection) with 31254 (... with ethmoidectomy, partial [anterior]), 31255 (... with ethmoidectomy, total [anterior and posterior]), 31256 (Nasal/sinus endoscopy, surgical, with maxillary antrostomy), or 31267 (... with removal of tissue from maxillary sinus), many commercial payers do, anyway. They consider the concha bullosa resection integral to opening the ethmoid sinus. They argue that the ENT has to go through the concha bullosa to get to the ethmoid anyway. Physicians beg to differ.

When your ENT performs 31254, 31255, 31256, or 31267, "you should be able to bill 31240 based on the original valuation of the RVUs," says Michael Setzen, MD, FACS, FAAP, chief of the Rhinology Section at  North Shore University Hospital in Manhasset, N.Y., and clinical associate professor of otolaryngology at NYU School of Medicine. The physicians who developed the valuation for the procedures "were of the opinion that the work involved in concha bullosa resection was over and above that performed on the ethmoid (or maxillary) sinus," Setzen says.

"There is additional work necessary to preserve the mucosa on both sides of the turbinate, preserve the lamella, and resect areas of exposed bone while preserving middle turbinate integrity," Setzen says of 31240. CCI edits support this logic, he says.

To fend off denials, the American Academy of Otolaryngology " Head and Neck Surgery says, try these methods:

• Include the vignettes for both procedure codes which show they are separate;

• Point out that CCI does not bundle the procedures;

• Include operative notes that distinguish the two procedures; and

• Members of AAO-HNS can contact the organization if the insurer does not overturn their coverage determination after submitting appeals.

One more possibility is to call on modifier 59 (Distinct procedural service). If you have a history with a payer that denies 31240 when reported with ethmoid or maxillary surgery, before you appeal, send the initial claim out with modifier 59 instead of modifier 51 (Multiple procedures). In endoscopic procedures, modifier 59 is often the best way to indicate a separate site and a separate procedure.

The third-party payer may need to update its software to unbundle this code pair. You can also explain that both codes require different levels of physician work, and that the concha bullosa is separate from an  ethmoidectomy.

Make sure you append modifier 59 to the correct code, says Vicky Varley O'Neil, CPC, CCS-P. "Modifier 59 should be billed with the secondary, additional, or lesser service" in the code pair, O'Neil says. In this case, that's 31240.

Most providers follow CCI, but some go a little further. "Private claims editing systems will build in additional edits," O'Neil says.

Document Separate Procedures

Your part: Tell your otolaryngologist that solid documentation can make the difference between 31240 payment on appeal and nonpayment. The surgeon should document the endoscopic excision of the concha bullosa well. The operative note should show all the work involved in the added procedure. Your otolaryngologist must clearly document the endoscopic resection of the middle turbinate's concha bullosa, coding experts say. Explain that describing all the work involved in the added procedure in the operative note will allow you to pinpoint the separate procedure and code for it appropriately.

Benefit: You'll be able to highlight the work that describes 31240. In the event of an appeal, solid 31240 documentation will go a long way to show the insurer that the endoscopic concha bullosa resection is indeed a separately identifiable procedure.