Otolaryngology Coding Alert

Nasal repair procedures such as rhinoplasties are among the most difficult services to obtain payment for because they are usually performed for cosmetic reasons. Related procedures, such as septoplasties and the repair of nasal vestibular stenosis (for which a new CPT code was created in 2001), may also be denied as cosmetic.

To obtain payment for these procedures when they are medically necessary, otolaryngologists should:

Use diagnosis codes that indicate the medical necessity of the procedure;

Provide clear and accurate documentation that supports the diagnosis codes and explains why the procedure was necessary; and

Appeal inappropriate denials.

Demonstrate Medical Necessity

Of the two types of rhinoplasties listed in CPT (primary and secondary), primary procedures are more likely to be performed for functional reasons (for example, an otolaryngologist may perform a functional rhinoplasty that includes septal repair on an adult with breathing difficulties whose nose was broken 17 years earlier). The manual includes three primary rhinoplasty codes:

30400 rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip; 19.78 relative value units (RVUs)

30410 rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip; 25.76 RVUs

30420 ... including major septal repair; 30.97 RVUs

Obtaining reimbursement for any of these procedures can be difficult because many carriers reject them as cosmetic without looking at the diagnosis or accompanying documentation, says Barbara Cobuzzi, MBA, CPC, CPC-H, president of Cash Flow Solutions, a coding and reimbursement firm in Lakewood, N.J.

Other payers may try to determine functional versus cosmetic percentage of the procedure and pay accordingly. This is absurd, Cobuzzi says, because you cant do one part of the procedure without the other.

Functional and cosmetic rhinoplasties can differ greatly. The ultimate purpose of the functional procedure (to improve airflow) often involves adding tissue, whereas the purpose of its cosmetic counterpart is usually to reduce the size of the patients nose by removing cartilage.

For example, when rhinoplasty corresponding either to 30400 or 30410 is performed to treat restricted airflow in the nasal passages, cartilage or bone grafts often are required to buttress the structure of the nose. In addition, such grafts may require significant additional work compared to cosmetic primary rhinoplasty.

Note: Placement of the graft is included in the rhinoplasty procedure, but obtaining the graft is separately payable and should be billed using the appropriate graft code. For bone grafts, use 20900 (bone graft, any donor area; minor or small [e.g., dowel or button]). For cartilage grafts, 20910 (cartilage graft; costochondral) or 20912 ( nasal septum) should be used, depending on where the graft was harvested. If, however, a graft is obtained from the septum and used to repair that structure, it is not separately payable.

Otolaryngologists performing a functional rhinoplasty should clearly note why the procedure was medically necessary, preferably in a separate paragraph or section of the operative report. For example, the patients history should document that the patient suffered from obstructed breathing and/or nasal trauma causing unsatisfactory breathing. The examination should note the internal and external nasal anatomy, as well as the patency of the patients nasal passages. An estimate of the percentage of obstruction for each side should be included.

Pre- and postoperative photographs, which can be very effective in convincing carriers that a procedure is medically necessary, should be included among the documentation whenever possible.

In addition, an appropriate ICD-9 code should be crosslinked to the procedure. For rhinoplasty, applicable ICD-9 codes include:

478.1 other diseases of nasal cavity and sinuses;
738.0 acquired deformity of nose;
873.3x open wound of nose, complicated;
905.0 late effect of fracture of skull and face bones; and
925.1 crushing injury of face and scalp.

Note: ICD-9 478.1 should be used for nasal obstruction (i.e., airway blockage caused by alar and/or nasal valve collapse, tip ptosis or twisted nasal cartilage).

Crosslink Correct ICD-9 Code to Septoplasty

Often, septoplasties are performed during the same session as the repair of nasal stenosis (30465). Code 30465 is not bundled with any other code, including septoplasty, in the latest version (7.1) of the national Correct Coding Initiative. Lee Eisenberg, MD, an otolaryngologist in private practice in Englewood, N.J., and a member of CPTs editorial panel and executive committee, believes septoplasty should be billable separately from the nasal stenosis repair, but he expects many carriers will bundle the procedure as included.

Septoplasties are usually functional, but may sometimes be performed for cosmetic reasons. As a result, carriers scrutinize this procedure, especially when it is performed with other services, such as functional endoscopic sinus surgery (FESS). For example, computerized editing software like McKesson-HBOCs Claimcheck will automatically flag a septoplasty claim for review. As a result, the claim will have to be resent manually with accompanying documentation.

Note: Septoplasties are frequently inappropriately denied when performed during the same session as FESS.

Furthermore, a functional septoplasty may be performed in conjunction with a cosmetic rhinoplasty. Therefore, medical necessity must be clearly indicated. This means providing precise and accurate documentation that includes an explanation of why the procedure was performed particularly if the claim is being appealed and the carrier will review the documentation.

Once again, link the appropriate ICD-9 code to the septoplasty (30520) on the HCFA 1500 claim form. Often, claims are denied because the diagnosis has not been correctly crosslinked to 30520.

Acceptable ICD-9 codes for septoplasty include:

470 deviated nasal septum
478.1
802.0 nasal bones, closed fracture
802.1 nasal bones, open fracture.

Choose Private Pay When Possible

Even when the correct ICD-9 codes are used and medical necessity is well documented, otolaryngologists can expect to receive denials on first submission and may have to appeal to obtain reimbursement. And, when finally forthcoming, reimbursement for the procedure may not be worth the time, work and risk involved, Eisenberg advises.

Eisenberg cites the potential high risk and the intense postoperative care involved when patients are treated with such cosmetic procedures, and notes the reimbursement is woefully inadequate. Normally, otolaryngologists may charge about $5,000 or more for a rhinoplasty. Managed care plans and Medicare, however, pay less than $1,000 for 30420 the highest paying of the three primary rhinoplasty procedures.

I would not do any external nasal work other than an open reduction of a nasal fracture for a managed care or Medicare patient except as a private pay. Given the potential risk, its just not worth the time and effort, Eisenberg says.

Otolaryngologists should explain the situation to their patients, Eisenberg says. The patient should be told that the rhinoplasty probably is not going to be a covered service, and that even if the carrier does cover it, the payment is so low that it barely covers the time and effort involved. He recommends billing the patient privately for the rhinoplasty and remitting back to the patient all reimbursement from the carrier for any functional repairs (e.g., 30520, septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft; 12.09 RVUs).

Note: For any procedure that may be construed as cosmetic (including rhinoplasty and blepharoplasty), be sure to have Medicare patients sign an advanced beneficiary notice to notify them that the service may not be covered and that they would then be responsible for payment.