Otolaryngology Coding Alert

The various CPT codes involving turbinate procedures are not always easily differentiated. If the otolaryngologist fails to indicate clearly what he or she does, there is no way for the coder to know which code to select. Additionally, there are coding guidelines not found in the national Correct Coding Initiative (CCI) that apply when reporting these procedures. Failure to follow these guidelines almost always results in denials.

There are three sets of turbinate pairs in the nose (superior, inferior and middle) that secrete mucous, providing humidity and keeping the inside of the nose clean. They can swell or shrink, thereby affecting the size of the nasal passages. Turbinates that are hypertrophied (enlarged or overgrown due to an increase in the size of constituent cells) contribute to nasal obstruction. Various procedures are performed to alleviate this condition, either alone or, more often, with other procedures, such as functional endoscopic sinus surgery (FESS) and septoplasty (When the septum is deviated to one side, the inferior turbinate on the other side often may enlarge and block the nasal cavity).

To reduce the size of or remove one or more turbinates, otolaryngologists may perform:
 

Excision 

Resection 

Reduction 

Ablation 

Cauterization 

Outfracturing 

Endoscopic excision or resection.

 CPT lists six codes for these procedures, including:
 

30130 -- excision turbinate, partial or complete, any method; 6.96 relative value units (RVUs)

30140 -- submucous resection turbinate, partial or complete, any method; 7.81 RVUs

30801 -- cauterization and/or ablation, mucosa of turbinates, unilateral or bilateral, any method, (separate procedure); superficial; 2.89 RVUs

30802 -- ... intramural; 4.49 RVUs

30930 -- fracture nasal turbinate[s], therapeutic; 3.11 RVUs

31240 -- nasal/sinus endoscopy, surgical; with concha bullosa resection; 4.75 RVUs 

(Dorland's Medical Dictionary defines the concha bullosa as a cystic distension of the middle nasal concha" " which is another term for the middle turbinate).

Understand Terminology To Select the Proper Code

30130/30140/30140-52: When describing turbinate procedures many otolaryngologists use the words "resection" and "excision" interchangeably. But because 30130 describes an excision and 30140 is used to report a submucous resection the precise definition of these and other terms associated with turbinate procedures needs to be understood.

Code 30130 describes the excision of all or part of the turbinate usually the inferior turbinate says Lee Eisenberg MD an otolaryngologist in private practice in Englewood N.J. and a member of CPT's editorial panel and executive committee. 

" Code 30130 should be reported when the otolaryngologist does not make an incision into the mucosa to resect the turbinate but rather goes in and excises mucosa and bone at the same time " Eisenberg says. He adds that in theory such an excision could also apply to the middle turbinates except when any ethmoid sinus surgery is performed on the same side.

A submucous resection is a more sophisticated procedure that requires an incision into the mucosa of the inferior turbinate which is elevated from the turbinate bone allowing it to be excised. Frequently some of the lateral turbinate mucosa is also resected. Any remaining mucosa is replaced over the bare bone of the remnant of the turbinate. Submucous resections are performed only on the inferior turbinates Eisenberg adds.

Note: Both 30130 and 30140 include the words "partial or complete " which means the entire turbinate bone need not be removed for either of these codes to be reported. Furthermore "any method" may be used to perform the excision or submucous resection.

Below the descriptor for 30140 CPT states "For reduction of turbinates use 30140 with modifier -52 (reduced services)." According to Eisenberg such a "reduction" involves performing an incision into the mucosa and removing only the lateral mucosa but not the turbinate bone itself.

30801/30802: These codes describe electrocautery or ablation on the turbinate mucosa. No incision or excision is performed. The codes differ in that 30801 involves a superficial or external cauterization on the surface of the mucosa whereas 30802 describes the destruction of the mucosa from within. According to Eisenberg such needle cautery is most commonly placed into the turbinate leading to internal destruction of the mucosa (30802).

Both 30801 and 30802 are "separate" procedures that are often components of more complex services (i.e. FESS surgery or septoplasty) and are not reported separately. If either of these procedures is performed on its own however or with an unrelated service it may be billed.

If either code is performed in conjunction with an unrelated service modifier -59 (distinct procedural service) should be appended to indicate that the turbinate electrocautery or ablation is not bundled with the other procedure. For example an allergic child who receives an adenoidectomy (42830 adenoidectomy primary; under age 12) may also have secondary swelling of the inferior turbinates. The swelling of the mucosa is cauterized internally. Therefore 30802-59 should also be reported.

30930: This code describes an outfracture in which the otolaryngologist places an instrument (usually a septal elevator) between the attachment of the inferior turbinate and the lateral wall of the nose and produces a fracture at the attachment of the inferior turbinate to the lateral nasal wall allowing the turbinate to move laterally and thereby improving the airway.

31240: This code combines FESS and middle turbinate resection using the endoscope. The procedure involves inspecting internal nasal structures with the endoscope and then placing scissors forceps or a microdebrider parallel to the endoscope and excising the affected portion of the middle turbinate.

The six codes above have several guidelines. For instance 31240 should never be billed with a resection of the middle turbinate (30130). Furthermore neither procedure should be billed with an ethmoidectomy (31254 nasal/sinus endoscopy surgical; with ethmoidectomy partial [anterior]; 31255 ... with ethmoidectomy total [anterior and posterior]) on the same side because the middle turbinate is part of the ethmoid sinus complex. If however the ethmoidectomy is performed on the other side the turbinate procedure may be billed separately using modifiers -LT (left side) -RT (right side) or -59 depending on carrier preference.

Another guideline which appears to be a clinical convention because no edit exists in the CCI is that neither cautery nor outfracture codes may be billed if excision/submucous resection (SMR) procedures were performed on the same turbinate on the same side. In other words only one procedure may be billed per turbinate per side; if the otolaryngologist performed an outfracture and then a submucous resection on the same side of the same turbinate only 30140 should be billed. If the otolaryngologist were to outfracture the turbinate on one side and perform an SMR on the opposite turbinate 30930-59 could be billed in addition to 30140.

Furthermore if the otolaryngologist performs an SMR on an inferior turbinate and an excision on the middle turbinate on the same side both procedures could be billed separately with modifier -59 attached to the 30130.

Note: If an ethmoidectomy was also performed on the same side 30130 could not be billed.

If both sides of the same turbinate (inferior or middle) require excision or SMR both 30130 and 30140 should be billed with modifier -50 (bilateral procedure) appended. Payment for bilateral procedures should be 150 percent of the fee paid when the procedure is performed on one side.

The descriptors for 30801 30802 and 30930 specify turbinate(s) both single and plural. This should mean that none of these codes may be billed with modifier -50 appended which holds true for 30801 and 30802. But according to HCFA's Fee Schedule 30930 may be billed as a bilateral procedure in spite of the CPT descriptor.

Both 30130 and 30140 have 90-day global periods whereas 30801 30802 and 30930 include a 10-day surgical package. Like many endoscopic sinus surgery codes 31240 has zero global days and if performed on both sides may be billed using modifier -50.

Otolaryngologists frequently bill for an SMR using 30140. But often when an independent coding specialist audits the practice the records contain no evidence that an SMR was performed notes Barbara Cobuzzi MBA CPC CPC-H an otolaryngology coding and reimbursement expert and president of Cash Flow Solutions in Lakewood N.J.

Cobuzzi says "To be able to code 30140 which pays at a higher rate the otolaryngologist has to demonstrate in the operative report that he or she incised the mucosa and resected the turbinate bone. If all the notes say is 'excision of turbinate ' only 30130 can be billed."

The key word Cobuzzi notes is "incision." When 30140 is appropriately billed the incision of the mucosa should be clearly noted. Coders should review all the procedure notes to ensure the correct procedure (not necessarily the procedure listed at the top of the operative report) has been reported.

Similarly to differentiate 30140 from 30140-52 the surgeon should describe incising the turbinate mucosa and resecting or excising the turbinate bone as well.

If an endoscopy with concha bullosa resection is performed the "Findings" section in the procedure notes should also mention that a concha bullosa was detected for example on a CT scan Eisenberg says. He notes that this is helpful if the claim is denied and must be appealed.

Note: Because SMR may also be performed on the nasal septum coders should carefully review the physician's procedure notes to determine if the procedure involved a turbinate or the nasal septum