Otolaryngology Coding Alert

Determine whether the procedure was -unusual- before you append 22

When you-re coding a procedure with an operative report that seems to repeat the same information twice, don't adjust your glasses -- the simple explanation could be that your surgeon performed a bilateral procedure.
 
Read on as in-the-trenches coders weigh in with their take on one tricky operative note.
 
The following op report details an endoscopic sinus procedure that you may have coded before, but this one has a twist.

Review the Op Report's Key Details

Patient's diagnosis: Chronic sinusitis with chronic nasal airway obstruction due to bilateral inferior turbinate hypertrophy.

Procedure overview: Bilateral endoscopic anterior and posterior ethmoidectomies, bilateral endoscopic maxillary antrostomies, and bilateral inferior turbinate excision.

The pertinent details of the operative report: I medialized the left middle turbinate and took down the uncinate using a Cottle and then removed it using straight-biting forceps. I entered the ethmoid bulla low using straight suction and took down the face of the bulla using up-through-biting forceps. I began the dissection posteriorly through the ethmoid air cell system into the posterior ethmoid air cell and identified the skull base.
 
I continued the dissection from posterior to anterior under 25 degree endoscopic visualization and removed small fragments of bone and inflammatory tissue as encountered into the frontal recess region. I opened the natural maxillary os using forward and backbiting instrumentation and placed the packs for hemostasis.
 
I then medialized the right middle turbinate and took down the uncinate using a Cottle and removed it using straight-biting forceps. I continued the dissection from posterior to anterior under 25 degree endoscopic visualization and removed small fragments of bone and inflammatory tissue as encountered. I identified the natural maxillary os with a ball seeker and opened it widely using forward and backbiting instrumentation. I placed packs for hemostasis.
 
I injected Xylocaine 1 percent with 100,000 of epinephrine into each inferior turbinate and middle turbinate. After waiting the appropriate time, I made an incision on the medial surface of each inferior and middle turbinate in their anterior third parallel to the floor of the nose.
 
I then raised superior and inferior flaps on each of the four turbinates and removed a part of the underlying bone on the medial surface of each of the four turbinate bones with a rongeur. I then out fractured each of the four turbinates. There appeared to be significant increase in the size of the nasal passages bilaterally.
 
The patient bled consistently the entire time that the hyperplastic tissue was in his sinuses. Overall, the patient lost three units of blood during the procedure. I placed a Murocel sponge into the middle meatus and then achieved hemostasis.

Break Down Your Coding Options
 
Step 1: Code the ethmoidectomies. Because the otolaryngologist performed surgical drainage of both of the patient's ethmoid sinuses, you can report 31255-50 (Nasal/sinus endoscopy, surgical; with ethmoidectomy, total [anterior and posterior]; bilateral procedure). The surgeon documents moving the dissection from posterior to anterior, which allows you to report the higher-paying 31255 instead of the basic code 31254 (- with ethmoidectomy, partial [anterior]).
  
Step 2: Report the antrostomies. The surgeon referenced opening the maxillary OS on both the left and right sides. Therefore, you can report 31256-50 (Nasal/sinus endoscopy, surgical, with maxillary antrostomy) to cover both procedures.

Step 3: Code the turbinate excisions. The otolaryngologist removed part of the turbinate bones in each of the four turbinates and then out-fractured the turbinates. For these inferior turbinate excisions, you should report 30130-50 (Excision inferior turbinate, partial or complete, any method).

Step 4: Consider modifiers. The surgeon refers to excessive bleeding during the ethmoidectomies and antrostomies. Because the surgeon dictates that the patient lost three units of blood, you should ask him whether he thinks that modifier 22 (Unusual procedural services) is warranted. If so, you should append modifier 22 to 31255 and 31256, and use 998.11 (Hemorrhage complicating a procedure) as a secondary diagnosis code on those line items.

Fortunately, you can forego modifier 59 (Distinct procedural service) on this claim, says Lori Pierson, BS, RHIA, CPC, coding specialist at Promedica Physician Corp., because the National Correct Coding Initiative does not bundle 31255, 31256 or 30130 with one another. 
 
And the payer should not confuse your billing 30130 for the inferior turbinates with the middle turbinates, because the definition of 30130 was changed in 2006 from -any turbinate- to -inferior turbinate,- 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 payer does try to bundle 30130 with the endoscopic sinus surgery, you can point out this definition change to them on appeal,- she says.

Step 5: Add your ICD-9 codes. You should link the surgery procedure codes to diagnosis codes 473.2 (Chronic sinusitis; ethmoidal) for the ethmoidectomy, 473.0 (Chronic sinusitis; maxillary) for the antrostomies, and 478.0 (Hypertrophy of nasal turbinates) for the turbinate excision, Cobuzzi says. 
 
Remember that Medicare and most other insurers will take a discount on your second and third line items. Therefore, you should list the codes in order from highest to lowest relative value units. Your claim should appear as:

 - 31255-50-22 linked to 473.2 and 998.11 
 - 30130-50 linked to 478.0  
 - 31256-50-22 linked to 473.0 and 998.11.

When you append modifier 22 to your claim, remember to increase your surgeon's fee accordingly.