Revenue Cycle Insider

Let these 2 Medicare LCDs be your guides.

If your otolaryngologist performs a rhinoplasty, you know there is a good chance a payer may deny the procedure due to medical necessity. That means your documentation must prove the surgery is reconstructive and not cosmetic.

So, to ensure your external nasal reconstruction procedure claims are denial proof, follow these three steps and ensure reimbursement is smooth and uncomplicated.

Begin by Understanding Medical Necessity

The Medicare policy outlined in local coverage determination LCD L39506 is a good place to start, for a number of reasons. First, it provides a clear definition of the procedure as one “that changes the shape or appearance of the nose while improving or preserving the nasal airway.” The definition goes on to note that rhinoplasty “can be functional, aesthetic, or both.” Simply put, Medicare and payers that follow Medicare guidelines will pay for functional rhinoplasties but not aesthetic ones.

But it really isn’t that simple.

The Medicare policy uses the American Society of Plastic and Reconstructive Surgeons definition of reconstructive surgery as surgery “performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, involutional defects, or disease.” On the other hand, surgeons perform aesthetic, or cosmetic, surgery “to reshape normal structures of the body in order to improve the patient’s appearance and self-esteem.”

Note these caveats: However, “some congenital, acquired, traumatic or developmental anomalies may not result in functional impairment, but are so severely disfiguring (e.g. but not limited to severe burns or repair of the face following a serious automobile accident) as to merit consideration for corrective surgery,” according to LCD L39506.

Additionally, Medicare considers cosmetic surgery “reasonable and necessary as long as infection, hemorrhage or other serious documented medical complication occurs, and the beneficiary has been officially discharged from the facility.”

So, specifically, Medicare considers rhinoplasty procedures as medically necessary under the following circumstances:

• To correct nasal airway obstruction due to “trauma, disease, congenital defect” that septoplasty/turbinectomy cannot correct or that has failed previously to correct
• To correct “non-septal, nasal obstruction due to vestibular stenosis”
• To correct a nasal or craniofacial deformity that is “causing a functional impairment”

Then Understand the Key Dx Codes

A second Medicare LCD, A56587, provides a comprehensive list of ICD-10-CM codes that provide medical necessity for rhinoplasty and other forms of reconstructive nasal surgery. Some of the key codes and code groups include

• C30.0 (Malignant neoplasm of nasal cavity)
• C43.31 (Malignant melanoma of nose)
• J32.- (Chronic sinusitis)
• J34.- (Other and unspecified disorders of nose and nasal sinuses)
• Q35-Q37 (Cleft lip and cleft palate)
• S02.2- (Fracture of nasal bones)

But beware this code: It may seem obvious, but LCD A56587 also directs you not to use Z41.1 (Encounter for cosmetic surgery) as a primary diagnosis code.

Then Understand Primary and Secondary Rhinoplasty Codes

CPT^® divides the rhinoplasty codes into primary and secondary. The primary codes are appropriate for patients who have not had the surgery before and are, therefore, more likely to need the surgery for functional reasons:

• 30400 (Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip)
• 30410 (… complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip)
• 30420 (… including major septal repair)

The secondary rhinoplasty codes designate surgeries performed after the patient has undergone a previous rhinoplasty, often because the previous rhinoplasty resulted in a complication, did not achieve the desired functional or cosmetic results, or did not treat the patient’s issues properly:

• 30430 (Rhinoplasty, secondary; minor revision (small amount of nasal tip work)
• 30435 (… intermediate revision (bony work with osteotomies)
• 30450 (… major revision (nasal tip work and osteotomies)

CPT^® also lists two other rhinoplasty codes. As their descriptors note, 30460 (Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columellar lengthening; tip only) and 30462 (… tip, septum, osteotomies) are secondary rhinoplasty codes, but the codes are specific to procedures performed primarily and separately from the plastic repair of cleft lip codes 40700-40720.

According to CPT^® Assistant December 2014 (Vol. 24: Issue 12), you’ll use 30460 and 30462 “to report cleft lip rhinoplasty procedures involving cartilaginous work and columellar lengthening.” These procedures “are not considered an inclusive component of the plastic repair of cleft lip codes … and can be reported separately … when performed.”

For secondary rhinoplasties, you’ll use Z42.8 (Encounter for other plastic and reconstructive surgery following medical procedure or healed injury) as the primary diagnosis code if the circumstances are appropriate. The code is not listed in LCD A56587 as justifying medical necessity for secondary rhinoplasties, however, so be sure to clarify with your payer before using it.

Use ABN When Needed

Even when the correct ICD-10-CM codes are used and medical necessity is well documented, you should expect to receive denials on first submission, and you may have to appeal to obtain reimbursement.

For any procedure that may be construed as cosmetic, be sure your Medicare patients sign an advanced beneficiary notice (ABN) to notify them that the service may not be covered and that they would then be responsible for payment. To cover practice expenses, it’s also a good idea to bill your patient privately for the rhinoplasty and remit all reimbursement back to the patient from the payer for any functional repairs.

Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC