Otolaryngology Coding Alert

Start with a solid understanding of when they’re necessary.

• 0406T – Nasal endoscopy, surgical, ethmoid sinus, placement of drug eluting implant
• 0407T – … with biopsy, polypectomy or debridement.

Now that we’re a few months into the year, how is the code implementation going? Follow the advice of these experts to learn how to find success when submitting these claims.

Point 1: Understand When They Apply

Codes 0406T and 0407T are designed to represent separate, stand-alone placement of a drug-eluting implant. Be careful of what other procedures your otolaryngologist performs during the same session, however. You cannot report 0406T or 0407T on the same claim as some procedures, depending on the circumstances. For example:

• Do not submit 0406T or 0407T with 31231 (Nasal endoscopy, diagnostic, unilateral or bilateral [separate procedure]) or 31237 (Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement [separate procedure]). Correct Coding Initiative (CCI) edits consider these procedures to be mutually exclusive. 
• Do not bill 0406T or 0407T with many of the traditional FESS codes, such as 31200 (Ethmoidectomy; intranasal, anterior), 31237 (Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement [separate procedure]), or 31254 (Nasal/sinus endoscopy, surgical; with ethmoidectomy, partial [anterior]). Some other procedures, such as 31238 (Nasal/sinus endoscopy, surgical; with control of nasal hemorrhage), are not on the exclusions list.

Point 2: Know How to Bill Them

A national payment rate has not been established for codes 0406T or 0407T. Because of this, providers should be prepared to reference a reasonable and appropriate crosswalk for payment when submitting these claims.

Codes 31231 or 31237 might be good cross references, some coders say. You also need to report the cost of the implant itself with a HCPCS code, regardless of the place of service or the treated sinus.

Hospital setting: When your surgeon performs the procedure in a hospital setting, most commercial payers will expect you to report S1090 (Mometasone furoate sinus implant, 370 micrograms). Submit C2625 (Stent, non-coronary, temporary, with delivery system) to Medicare (and possibly other payers that have their own rules or contract stipulations).

Office setting: You’ll still submit S1090 to most commercial payers if the procedure takes place in your office. You’ll shift to J3490 (Unclassified drugs) for Medicare and commercial payers that do not accept S codes.

Important: Remember that Medicare and many commercial payers do not allow separate reimbursement for implants or supplies. You still need to include the device on your claim, however, to fully document the service and allow for data collection that might lead to reimbursement or other codes in the future. 

Point 3: Use a Different Tactic for Frontal Sinus Reporting

In March 2016, the FDA expanded the approval of PROPEL mini to include the frontal sinus. You cannot report 0406T or 0407T for these procedures since the descriptors specify the ethmoid sinus. Instead, the appropriate code will be determined by the situation.

• Following frontal sinusotomy (31276, Nasal/sinus endoscopy, surgical with frontal sinus exploration, with or without removal of tissue from frontal sinus) – Do not include an additional code for the implant placement.
• Following frontal balloon dilation (31296, Nasal/sinus endoscopy, surgical; with dilation of frontal sinus ostium [e.g., balloon dilation]) – Report the implant placement with 31299 (Unlisted procedure, accessory sinuses) in addition to 31296. Include clear documentation of the service that 31299 represents.
• Following surgery as a separate, stand-along procedure (with placement in the frontal sinus ostia) – Submit 31299.

Crosswalk ‘unlisted’: Whenever you submit an unlisted code, your challenge is to find a comparable procedure to use as a benchmark for work load and reimbursement. For 31299 in this situation, 31231 and 31237 might both be appropriate for either the ethmoid or frontal sinus. Provider might be able to use these codes as a baseline and then add additional RVUs (supported by detailed documentation) when negotiating payment from the insurer.