Otolaryngology Coding Alert

Do you know an excision from a reduction? Your reimbursement depends on it

Considering that turbinate excision (30130) pays more than $350 per surgery, you can't afford to skimp on your documentation and face a claim denial. The following expert tips can help you shore up your turbinate coding and keep the denials at bay.

Determine Whether Reduction Means Excision

One of the most common turbinate coding errors is that coders often confuse the terms -reduction- and -excision.- Because these terms correspond to different codes, you should know these procedures like the back of your hand.

Consider the following operative note: -Xylocaine 1 percent with 100,000 of epinephrine was used to inject each inferior turbinate and middle turbinate. Using a Greenwald rongeur, each inferior turbinate was reduced by about 40 percent, and the edges were cauterized with a suction cautery. Both middle turbinates were also reduced in the same manner.-

The surgeon refers to a -reduction- of the inferior turbinates and the middle turbinates by 40 percent. Surgeons who use the term -reduction- often mean that they performed radiofrequency to reduce the turbinate.

But the physician also refers to a rongeur. Surgeons usually use rongeurs to actually excise the bone, says Cindy Terry, coding and reimbursement manager at ENT Billing Associates in Worcester, Mass. When otolaryngologists say that they excised a bone, they mean that they actually removed all or part of it. So which of the following codes is correct?

- 30130 -- Excision inferior turbinate, partial or complete, any method

- 30140 -- Submucous resection inferior turbinate, partial or complete, any method

- 30802 -- Cautery and/or ablation, mucosa of inferior turbinates, unilateral or bilateral, any method; intramural

- 30999 -- Unlisted procedure, nose.

Tip: Your best bet is to check with the surgeon and ask him whether he performed radiofrequency ablation of the turbinate. If so, you should report 30802.

If he excised the turbinates, you should report 30130 for the inferior turbinates and 30999 for the middle turbinates -- and give the otolaryngologist a few documentation tips for the future.

First, remind him that he should document an excision rather than a reduction. In addition, ask him what he meant when he referred to -40 percent.- If he cut out 40 percent of the bone, he should say that, because reduction by 40 percent may mean that he reduced the size using radiofrequency ablation and returned it to its prediseased state.

Watch RFA as Closely as the Auditors

What's the big deal? Beyond the fact that you-re coding incorrectly if you report 30130 for ablation procedures, you-re also setting yourself up for accusations of upcoding. The Medicare Physician Fee Schedule pays about $350 (not adjusted for geographic differences) for 30130 if you perform the procedure in a facility, but it only pays $173 for 30802 in a facility.

Note: Some otolaryngologists avoid 30130 for radiofrequency ablation (RFA) of the turbinates, but they report 30140-52 (Reduced services) instead. This is also incorrect.

According to the American Academy of Otolaryngology -- Head and Neck Surgery Web site, -For RFA of the turbinates, use CPT 30802 or CPT 30999. Submucous resection of turbinates is not the best suited code, even when the 52 modifier for reduced services is applied.-

Auditors are watching surgeons who frequently bill 30140-52 and 30130 because they have found that practices over-report these codes when in actuality they performed RFA. Be sure your documentation clearly demonstrates the method the surgeon used to treat the turbinates.

Report 30140 Only When Surgeon Incises Mucosa

If you-re still confused about the difference between a resection and an excision, remember that an excision (30130) describes the removal of all or part of the turbinate. During the procedure, the surgeon does not make an incision into the mucosa to resect the turbinate. Instead, he excises mucosa and bone at the same time, cutting out the mucosa and the bone entirely.
 
A submucosal resection (30140), however, requires an incision into the mucosa of the inferior turbinate, which is elevated from the turbinate bone, allowing the surgeon to excise the bone while preserving the mucosa. The surgeon may resect some of the lateral turbinate mucosa, and then he replaces any remaining mucosa over the bare bone of the remaining turbinate.

Documentation tip: If the surgeon's note only says -Excision of turbinate,- and the documentation does not describe the procedure in the surgery details section, you cannot report 30140, even if the procedure summary at the top of the page says -Submucous resection turbinate.- That's because the op report's -Procedure- or -Surgery Description- must include all the surgery's details. If the surgeon refers to the complex surgery only in his op note's summary at the top of the page, you cannot report the code.

When is modifier 52 warranted? If the surgeon documents an incision of the mucosa along with outfracturing, you should report 30140-52. The debulked turbinate is what results in the -reduced- turbinate that CPT refers to, 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. If the surgeon documents an incision into the turbinate mucosa and a resection or excision of the turbinate bone as well, you can report 30140 without any modifiers.