Otolaryngology Coding Alert

Order your codes incorrectly on your claim, and you may miss out on $104.

For functional endoscopic sinus surgeries (FESS) documentation, global periods, and modifiers, you need to be extra vigilant if you want to recoup the highest possible ethical reimbursement the first time you submit your claim.

Dodge these three pitfalls, and your claim will sail through your payers' hands, no questions asked.

Pitfall 1:You Don't Verify Endoscopic Procedure

Otolaryngologists use FESS (31237-31288) as a sinus surgical method. The term "functional" distinguishes this type of endoscopic surgery from nonendoscopic, more conventional sinus surgery procedures. The main  purpose of FESS is to restore normal drainage of the sinuses.

Warning: Before you apply nasal/sinus endoscopy codes (31231-31294), make sure your otolaryngologist performed and documented endoscopic procedures. Auditors reported encountering a few cases in which physicians performed sinus procedures via Caldwell-Luc antrotomies or frontal sinusotomies and not via endoscopy (or at least the otolaryngologist did not document via endoscope). Despite this lack of detail, the coders still used endoscopy codes.

Do this: Reserve the FESS codes for cases in which the operating room (OR) supports via endoscopy. The Caldwell-Luc (31020-31032) and frontal sinusotomy (31070) require documentation that specifies through the nose or a trephine (hole).

Pitfall 2:You Assume Multi-Day Global Periods

When your ENT sees a FESS patient postoperatively in the office, reporting services can get tricky. For FESS (31237-31288 except 31239), "there is no postoperative period," says Fariba Nesary, CPC, billing supervisor at University ENT, in Albany, New York.

Keeping that in mind, here's how to report these visits: If your physician sees the patient for an office visit postoperatively FESS with no other surgeries performed, you should report that visit (99212-99215, Office or other outpatient visit for the evaluation and management of an established patient ...) with no modifier. The same rule applies if you have to bill any other procedure, such as debridement (31237, Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement [separate procedure]) performed on the patient after his FESS, Nesary adds.

Although Medicare indicates a zero-day global period for most FESS procedures, codes with zero-day global periods still include a very small E/M component. When your otolaryngologist documents that an E/M service is significant and separately identifiable from the minor E/M included in debridement (31237), you can apply modifier 25 (Significant, separately identifiable evaluation and management service on the same day of a procedure or other service) to the E/M code.

If the initial surgery codes, such as a septoplasty (30520, Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft), create an existing global period and the ENT debrides the sinus during that period, append modifier 79 (Unrelated procedure or service by the same physician during the postoperative period) to 31237. The debridement is for the sinus, which is totally unrelated to the septoplasty work that is done on the septum and turbinates.

Pitfall 3:Your Codes Aren't Listed by Highest RVU

If you're not looking at your relative value units (RVUs), you could be allowing payers to reimburse your practice less than your practice ethically deserves. You should always list the code with the most RVUs first.

When coding for endoscopic sinus surgery, you should start with the procedure that has the most value. "In the New York area, I usually find it is the complete ethmoidectomy,so I put that at the top. Then -- in descending order -- list the procedures with lesser value," says Michael Setzen,MD, clinical associate professor of otolaryngology at New York University School of Medicine.

Example: Your surgeon performed:

• a right-sided total ethmoidectomy (31255, Nasal/sinus endoscopy, surgical; with ethmoidectomy, total [anterior and posterior]),

• a septoplasty (30520, Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft),

• maxillary antrostomy (31267, (Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus)

• with tissue removal frontal sinusotomy (31276, Nasal/sinus endoscopy, surgical with frontal sinus exploration, with or without removal of tissue from frontal sinus), and • sphenoidotomy with tissue removal (31288, Nasal/sinus endoscoy, surgical, with sphenoidotomy; with removal of tissue from sphenoid sinus).

Note how ordering the surgeries can make a difference.This is the correct order:

CPT                    RVU             RVU with Multiple Surgery Discount

30520                15.03                 15.03

31276-51           13.69                 6.845

31255-51           10.86                 5.43

31267-51           8.57                 4.285

31288-51           7.25                3.625

TOTAL non-geo adj RVU:     35.215

If the surgery was misordered, the result could end up like this (worst case):

31288                       7.25              7.25

31276-51                  13.69            6.845

31255-51                  10.86            5.43

30520-51                15.03              7.515

31267-51                8.57                4.285

TOTAL non-geo adj RVU: 31.325

That's a loss of 3.89 RVUs. If you multiply that by the current conversion factor of $36.0666 (non-geographic adjusted), your practice would be out $140.30 it deserves -- all because you put the lowest RVU procedure first instead of the highest RVU procedure.