Otolaryngology Coding Alert

Persistence may be your strongest weapon in the battle for payment for post-sinus surgeries. Although services, such as debridements, performed after functional endoscopic sinus surgery (FESS) are separately payable according to HCFAs fee schedule, private carriers often deny these claims or follow guidelines that include a global period for FESS.

If FESS was performed during the same operative session as another procedure (e.g., septoplasty or turbinectomy) with a 90-day global period, obtaining payment for post-FESS services from local Medicare carriers may also be difficult: The carrier may incorrectly determine that the debridements are connected to the septoplasty and include them in that procedures global surgical package.

Coding Services Following FESS

After endoscopic sinus surgery, patients may require additional care, including debridement, control of epistaxis and E/M services.

For example, a 40-year-old female patient undergoes extensive sinus surgery involving the maxillary, ethmoid, sphenoid and frontal sinuses. No turbinate work or septoplasty is performed. The following day, the patient returns to the physicians office for an evaluation and removal of the packing. One week later, she again returns to the otolaryngologist, who finds extensive crusting requiring debridement in both ethmoid sinuses.

According to Barbara Cobuzzi, MBA, CPC, CPC-H, an otolaryngology coding and reimbursement specialist and president of Cash Flow Solutions in Lakewood, N.J., the original surgical session would be coded as follows:

31255-50 nasal/sinus endoscopy, surgical; with ethmoidectomy, total [anterior and posterior]; bilateral procedure (12.54 relative value units [RVUs] x 1.5);

31267 ... with removal of tissue from maxillary sinus (9.65 RVUs);

31276 ... with frontal sinus exploration, with or without removal of tissue from frontal sinus (15.11 RVUs); and

31288 ... with removal of tissue from the sphenoid sinus (8.28 RVUs).

According to HCFAs fee schedule, all four FESS procedures listed have zero global days. Therefore, any services performed thereafter should be separately payable by local Medicare carriers as well as by private payers who follow HCFA payment guidelines or use the relative value/resource-based schedule for reimbursement.

Accordingly, the next-day visit to evaluate the patient and remove the packing should be coded 9921x (established patient visit), depending on the level of E/M service (based on history, exam and medical decision-making) provided. No modifier is needed because the examination is not being performed during the global period of another procedure.

The debridement performed on the patient a week later is also separately payable and should be reported using 31237 (nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement [separate procedure]). Because the debridement is performed in both left and right ethmoid sinuses, modifier -50 (bilateral procedure) should be appended to 31237. No other modifier is required because again the original FESS has zero global days in its surgical package.

Note: Only one debridement per side may be billed during a surgical session. For example, if the otolaryngologist debrides a maxillary sinus on the right and an ethmoid sinus on the left, 31237-50 should be billed. If ethmoids on the left and right are debrided along with the right maxillary sinus, 31237 still may be billed only once again with modifier -50 attached. If two or more sinuses on the same side are debrided during the same session, 31237 may be billed once and modifier -50 should not be appended.

Billing Postoperative Services

If a surgical procedure with a global period is performed during the same session as a FESS procedure, any services provided postoperatively are separately payable if the services are unrelated to the procedure with the global, which is indicated by appending a modifier to the service when appropriate. For example, a debridement performed after FESS and septoplasty (30520) is typically related to the sinus endoscopy, not to the septoplasty. In such situations, modifier -79 (unrelated procedure or service by the same physician during the postoperative period) should be appended to 31237. Modifier -24 (unrelated evaluation and management service by the same physician during a postoperative period) should be appended to an E/M code to indicate the service is unrelated to the septoplasty.

For example, a 67-year-old male undergoes a bilateral ethmoidectomy (31255-50), as well as a maxillary sinusotomy with removal of tissue (31267). A septoplasty (30520) is also performed. On the day after surgery, the patients packing is removed. Four days later, he returns with an episode of epistaxis (nosebleed). The otolaryngologist evaluates the bleeding and controls it endoscopically. Ten days later, the patient returns with crusting and a debridement is performed.

Because the septoplasty includes a 90-day global period, any E/M relating to the surgery performed cannot be billed separately, Cobuzzi says. For instance, the visit on the day after surgery during which the otolaryngologist removed the packing should be coded using nonpaying code 99024 (postoperative follow-up visit, included in global service).

The endoscopic epistaxis control should be billed using 31238 (nasal/sinus endoscopy; with control of epistaxis). Modifier -79 should be appended to 31238 to indicate that the epistaxis is unrelated to the septoplasty. Similarly, modifier -79 is attached to any subsequent debridement (31237).

The office evaluations that led to the decision to control the patients epistaxis and perform a debridement are included in the surgical package of those services or considered part of the original septoplasty.

Same-day E/M and Procedure

To be paid separately, an E/M service performed on the same day as a surgical procedure must have modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended. To use modifier -25 appropriately, however, the E/M service must be significant and separately identifiable. If all the otolaryngologist did was take a quick look at the patient and treat the problems, the visit is included in the debridements zero-day global surgical package.

Any E/M service that is significant and separately identifiable from the septoplasty may be billed with modifier -24 appended. However, the visit would have to be completely unrelated to the septoplasty and be for an entirely different problem (with a different diagnosis).

Without a new problem (for example, the patient has serous otitis media), E/M services are unlikely to be separately payable because it would be difficult to claim that an E/M service related entirely to the FESS was completely unrelated to the septoplasty.

Note: Even if multiple debridements are planned and performed, modifier -79, not -58 (staged or related procedure), is correctly appended to 31237. Although the debridements in many ways fit the definition of a staged procedure, modifier -58 is incorrect because it makes an incorrect link between the debridements and the septoplasty (i.e., the modifier is used to indicate that a service normally included in the septoplastys global period should, in this case, be separately payable because it was preplanned). In this case, however, the debridement is unrelated to the septoplasty which is more accurately indicated by appending modifier -79.

Appeal Inappropriate Denials

Many otolaryngologists report routine initial denials for correctly coded and billed post-FESS debridements if a septoplasty also was performed during the initial operative session.

It takes a lot of effort to get some of these claims paid, says Stella Almassian, administrator of the department of otolaryngology at Northwestern University in Chicago. We always have to appeal postoperative debridements, especially if a septoplasty was involved, regardless of the modifiers we use.

On appeal, Almassian stresses to the insurer that the sinus debridement is related only to the sinus surgery, which has zero global days.

The claim may be initially denied on postpayment review because this first level of appeal is adjudicated by the local Medicare carrier that denied the initial claim, Cobuzzi adds. When the claim goes to a second-level appeal before an independent fair hearing officer, the denial should be overturned as long as there is documentation to show that the debridement was:

medically necessary;
part of the clinical pathway for FESS only;
performed in the sinuses; and
played no role in the healing of the septum.

Denials by private carriers are best deflected when such claims are handled proactively, says Lee Eisenberg, MD, an otolaryngologist in private practice in Englewood, N.J., and a member of CPTs editorial panel and executive committee. He adds, however, that precertification of the debridements before the FESS surgery does not guarantee payment.

Almassian concurs. When we perform FESS surgery, we also precertify a couple of debridements postoperatively. But even so, we have denials after the fact. She notes that the carriers cite the standard disclaimer that precertification is no guarantee of payment and that the medical necessity of the procedure determines whether the claim will be paid.

Instead, Eisenberg recommends obtaining a predetermination of benefits (preferably in writing) from the carrier while precertifying the procedure. He notes that some private carriers will pay for a predetermined number of debridements after FESS.

If the private carrier denies a debridement or other post-FESS service inappropriately, file an appeal. If the carrier uses HCFAs fee schedule to reimburse procedures but has added a global period to FESS codes, the appeal should emphasize that the RVUs for the procedure were calculated based on a zero-day global period and, therefore, tacking on a 10-, 15- or 45-day global period without boosting reimbursement accordingly is inappropriate.

If the appeal fails, file complaints with the carriers medical director and the state insurance commissioner, or even reconsider your arrangement with the carrier.