Otolaryngology Coding Alert

Somnoplasty, a technique that uses low-energy, low-temperature radio-frequency to remove tissue obstructing airflow in the upper airway originally developed to stop snoring, is now approved for use with four distinct procedures uvulopalatoplasty, glossectomy, tonsillectomy and turbinate reduction to treat obstructive sleep apnea (OSA) or, in the case of turbinate reduction, nasal obstruction.

Note: Medicare and some other carriers consider snoring without an associated sleep disorder a cosmetic problem, meaning that somnoplasty of the soft palate, or any other treatment for a severe snoring problem, is not a covered service. Therefore, somnoplasty performed to treat a snoring problem should be billed the same as cosmetic surgery, for which otolaryngologists are paid directly by the patient.

Coding the Procedures

CPT generally does not distinguish procedures based on instrumentation (or illumination or magnification), and therefore does not include specific codes to describe uvulopalatoplasty, glossectomy, tonsillectomy and turbinate reduction performed with somnoplasty.

Consequently, if somnoplasty is used to remove a patients tonsils, the appropriate codes are 42826 (tonsillectomy, primary or secondary; age 12 or over) or 42825 ( under age 12). No modifier need be attached to the tonsillectomy code because 42825-42826 are the only available tonsillectomy codes.

Note: Somnoplasty is not used to remove infected tonsils. Rather, the procedure is used if the tonsils are hypertrophied and contributing to an airway obstruction.

When somnoplasty is performed on the base of the tongue, 41120 (glossectomy; less than one-half tongue) should be used. Modifier -52 (reduced services), however, should be appended to the glossectomy code.

At present there is no applicable code for reduction of the tongue, whether by laser, radiofrequency or cautery, says Lee Eisenberg, MD, an otolaryngologist in private practice in Englewood, N.J. and a member of CPTs editorial panel and executive committee. He notes that 41120 is understood to mean more than a simple reduction of tissue.

Similarly, reduction of nasal turbinates using somnoplasty should be coded 30140-52 (submucous resection of turbinate-reduced services) to indicate to the carrier that the procedure was not a complete submucous resection, but rather a reduction of turbinates. Although CPT does not include a code that specifically describes turbinate reduction, it does specify, for reduction of turbinates, use 30140 with modifier -52.

The closest code to removal of tissue from the soft palate (42145, palatopharyngoplasty [e.g., uvulopalato-pharyngoplasty, uvulopharyngoplasty) describes a more extensive procedure involving removal of tissue from the patients pharynx. Although 42145 with modifier -52 appended correctly describes a uvulopalatoplasty using somnoplasty, obtaining reimbursement for the procedure may prove difficult.

Reimbursement Problems and Solutions

Local medical review policies rarely mention somno-plasty. Many carriers, however, have issued policies indicating that a related procedure, laser-assisted uvulo-palatoplasty (LAUP), is a noncovered service. Most carriers specifically instruct otolaryngologists not to use 42145-52 to bill LAUP, but rather to use an unlisted procedure code (i.e., 42299, unlisted procedure, palate, uvula; or 31599, unlisted procedure, larynx) that is then denied.

Although somnoplasty is conspicuously absent from most local medical review policies, some carriers have issued policy statements on the technique in their monthly bulletins. For example, in its December 1999 bulletin, Xact Medicare Services (now HGSA Administrators), the local Medicare carrier in Pennsylvania, issued a policy disallowing coverage of the procedure because its clinical efficacy has not been proven.

Similarly, Palmetto Government Benefits Administrators, the Medicare carrier in South Carolina, states, Somnoplasty is not felt to be safe and effective for sleep disordered breathing for Medicare purposes.

The above policies do not specify, however, whether noncoverage of somnoplasty refers specifically to the soft palate procedure or is meant also to include glossectomy, tonsillectomy and turbinate reduction.

Payment for somnoplasty procedures vary by carrier, says Teresa Thompson, CPC, an independent otolaryngology coding and reimbursement specialist in Sequim, Wash. Some carriers view the procedures as experimental, others say its OK. Carriers also may cover some of the procedures but not others, depending on the procedure performed and the reason for doing it.

Note: Private carriers also vary on somnoplasty coverage. Some reportedly reimburse soft palate somnoplasty to treat OSA on review.

Payment for base of tongue somnoplasty for OSA presents a different challenge. In a March 3, 2000, letter to the president of Somnus Medical Technologies, Ann B. Fagan, RHIA, senior medical coding analyst, division of acute care, purchasing policy group, Center for Health Plans and Providers, HCFA, stated that somnoplasty to destroy tissue and reduce the volume of the tongue to treat OSA should be coded 41120 and specifically notes, reduction or destruction of tissue, whether by scalpel, laser or radiofrequency energy, falls under this code.

Medicare carriers, however, are not bound to follow these interpretive statements unless they are in the form of a policy mandate: Many carriers, both Medicare and private, will not cover base of tongue somnoplasty. Therefore, Eisenberg recommends obtaining a predetermination of payment for the procedure in writing from the carrier. This is especially important because the code requires a modifier [-52] and the procedure must be repeated to obtain the desired results.

Note: The repeat procedures, which are performed on subsequent days, should be billed with modifier -58 (staged or related procedure) as well as modifier -52 appended.

Eisenberg advises that a predetermination of payment, in writing, will protect the provider if the carrier issues a denial. He notes that simply precertifying a procedure is insufficient because most contracts state that precertification does not guarantee payment.

Tonsillectomy, Turbinate Reduction Often Covered

Medicare and private payers will likely pay tonsillectomy by somnoplasty. Because tonsillectomies by somnoplasty are not usually performed on infected tonsils, but rather to treat an airway obstruction due to tonsillar hypertrophy, some carriers may mistakenly apply their policy of noncoverage of somnoplasty of the soft palate to this procedure also, Eisenberg warns. Therefore, you should obtain a predetermination of payment for this procedure as well.

Eisenberg also recommends asking carriers to predetermine not only that the procedure will be paid but the dollar amount as well. If the carrier approves, for example, somnoplasty for tonsillectomy, you need to know how much payment to expect because the disposable handpieces [electrodes that attach to the tissue being removed] required to perform somnoplasty may not be separately reimbursed. If the carrier does not cover the cost of the handpieces, the otolaryngologist should explain to the patient that the supply is not covered and ask him or her to pay for it.

The cost of the handpieces is also a factor when billing for turbinate reductions by somnoplasty. Many carriers also cover this procedure, as long as modifier -52 is appended to 30140 and the operative report specifies that the turbinates were reduced.

It all goes back to what the somnoplasty actually achieved, Thompson says. If the op note describes a reduction, 30140 can be billed with modifier -52. Ablation of turbinates, however, requires a different code (30802, cauterization and/or ablation, mucosa of turbinates, unilateral or bilateral, any method [separate procedure]; intramural). This code, although not inappropriate, reimburses at a lower rate and barely covers the price of the handpiece.

Prospective Documentation

Communication with the carrier, in writing, before the procedure takes place is required to increase the possibility that the service will be covered. The otolaryngologist may be asked (or should offer) to provide the carrier with prospective documentation, such as supporting evidence that somnoplasty is in the patients best interest and may also save the carrier money later (typically, somnoplasty procedures bill for much less than their traditional counterparts).

The operative note should include a findings section that explains the medical necessity for the procedure and also explains why radiofrequency was used (in essence, the same information provided prospectively to the carrier).

For example, Eisenberg says, postprocedure documentation could state that, based on the patients history, the otolaryngologist determined that somnoplasty would be effective and, furthermore, would prevent patient disability, such as hospitalization and an extended recovery time that keeps the patient away from work and family.

Any clinical information that supports the somnoplasty or its coverage such as the HCFA letter mentioned earlier or a record of the patients sleep studies and other charts that justify the procedure over a continuous positive airway pressure machine (because the reviewer may want to ensure that standard sleep apnea treatments were attempted before the somnoplasty was performed) should also be included.

Tip: Modifier -52 may generate automatic payment without review, which can be dangerous if the service is deemed noncovered during a subsequent audit. If a written predetermination of payment has not been obtained, report the service with an unlisted procedure code instead. This forces the carrier to read the operative report and effectively render a postdetermination of payment for the somnoplasty procedure. In addition, patients should be asked to sign a waiver agreeing to pay for the service themselves if the carrier decides not to cover the procedure.