Otolaryngology Coding Alert

All rhinoplasty patients undergo the procedure for looks, right? Wrong. Believing this myth could send you searching for a "payable" code when all you really need to get paid is to meet the insurer's condition criteria or obtain a signed financial responsibility statement.

One ENT coder was concerned that insurers sometimes consider the rhinoplasty codes cosmetic. So, she wanted to know if another CPT code option existed.

"The condition's coverage determination criteria really drive Medicare payment," said Stacie L. Buck, RHIA, CCS-P, LHRM, RCC, in "ABN and Medical Necessity Essentials" presented by audioeducator.com. See if you can unlock the payment door for a rhinoplasty and septoplasty in which the patient had nasal obstruction and septal deviation due to previous trauma.

Before proceeding with functional nasal reconstruction, staff should contact the insurer to make sure the procedures are covered, says Ben Willis, biller with Accurate Medical Billing in Tennessee. To get paid for rhinoplasty, you have to find out what criteria you need to meet. For instance, Blue Cross Blue Shield of North Carolina may cover a rhinoplasty:

- for deformities of the bony nasal pyramid (nasal bones and nasal process of the maxilla) that:

a. directly cause significant and symptomatic airway compromise, sleep apnea, recurrent or chronic rhinosinusitis, and

b. are not responsive to appropriate medical management.

- Or, for deformity caused by specifically documented trauma within the previous 18 months.

Roadblock: When trauma or injury occurred more than 18 months ago, the insurer considers rhinoplasty cosmetic and therefore not covered.

The rhinoplasty featured in the case study is medically necessary to alleviate a problem that the patient is having. To indicate medical necessity, get the rhinoplasty preauthorized using 478.1x (Other diseases of nasal cavity and sinuses) and 470 (Deviated nasal septum). Don't forget to add on the trauma diagnosis, such as 905.0 (Late effect of fracture of skull and face bones).

Make sure you have rock-solid documentation showing the nasal obstruction and the septal deviation. "Expect to go to battle with your records even for a functional surgery," says Michael Setzen, MD, FACS, FAAP, clinical associate professor in otolaryngology at NYU School of Medicine and section chief of rhinology at North Shore University Hospital in Manhasset, N.Y. You might need to send in copies of the sinus endoscopy and/or sinus CT scan with good documentation showing that medical therapy failed.

Blue Cross Blue Shield of North Carolina might request the following documentation:

- Preoperative photos must be submitted consisting at a minimum of legible frontal, lateral and columellar views.

- Submit complete medical records including patient history, documentation of sleep apnea and other symptoms of breathing obstruction (for instance, nasal stuffiness, dryness, mouth breathing, etc.), including failed conservative treatment.

- If result of trauma or injury, include medical records documenting history of trauma or injury with date of injury and any other related surgeries.

After submitting the paperwork, get a preauthorization number for the covered procedures. This way you can easily appeal for payment if the insurer later denies it, Willis says.

Out: If an insurer does not cover the rhinoplasty, inform the patient, including an accurate estimate of her financial responsibility if she decides to proceed. Have the patient sign that she understands the cost, Willis says.

You-ll also need to include the financial bottom line for carriers. "Medicare is going to require that the estimated cost be included on the form starting in September -- that's a big change," says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, CPC-OBGYN, CPC-CARDIO, manager of compliance education for the University of Washington Physicians and Children's University Medical Group Compliance Program.

Although you can use a home-grown form for private payers, Medicare requires you to use a specific form. Without a valid advance beneficiary notice (ABN), "Medicare will not allow you to be reimbursed for the service or collect money from the patient," says Kara Hawes, CPC-A, coder with Advanced Professional Billing in Tulsa, Okla.

Change: You no longer need to use a notice of exclusions from Medicare benefits (NEMB). Medicare previously required this form for services that CMS statutorily excluded, such as cosmetic surgery. Carriers will not accept this form after Sept. 1. You can download new form CMS-R-131, effective March 3, from http://www.cms.hhs.gov/BNI/Downloads/CMSR131G.pdf.

CMS indicated G modifiers are optional, Buck says. "Some carriers, however, such as First Options in Florida, are requiring them." Here's how they work:

When you have a functional rhinoplasty that you are afraid Medicare may deny for medical necessity reasons, use modifier GA (Waiver of liability statement on file). For instance, if the surgeon is performing rhinoplasty with major septal revision (30420, Rhinoplasty, primary; including major septal repair) and you want the carrier's determination so you can bill the patient in the event of a denial, you could report 30420-GA.

Modifier GY (Item or service statutorily excluded, does not meet the definition of any Medicare benefit ..) applies when Medicare excludes the service and you-re using the new ABN as you would have used the NEMB in the past. For a cosmetic rhinoplasty, such as 30410 (Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip), you would indicate you have a signed ABN that makes the patient financially responsible with 30410-GY.

If you forget to get an ABN when you should have, use modifier GZ (Item or service expected to be denied as not reasonable and necessary). You cannot bill the patient when Medicare denies the service.