Otolaryngology Coding Alert

Otolaryngologists in growing numbers are reporting that when they bill for a septoplasty (30520, septoplasty, or submucous resection, with or without cartilage scoring, contouring or replacement with graft) performed during the same session as 30140 (submucous resection of turbinate, partial or complete, any method), the 30140 is being denied. If proper documentation is submitted to the carrier, both codes should be paid. These denials are inappropriate and should be appealed vigorously, coding specialists say.

Otolaryngologists and coding specialists agree there is no medical justification for bundling the two procedures. They are performed on different anatomical sites, the only common characteristic being that they both take place somewhere in the nose. And whereas the septum is made of cartilage, turbinates are bony projections. A septoplasty is performed to correct a deviated nasal septum that causes nasal obstruction, while resection of turbinates is done for turbinate hypertrophy (478.0) which also contributes to nasal obstruction.

The roof, septum and turbinates are three distinct, separate parts of the nose, says Gretchen Segado, MS, CPC, assistant compliance manager at Thomas Jefferson University in Philadelphia, citing the American Academy of OtolaryngologistsHead and Neck Surgeons (AAO-HNS).

Still, the denials continue to roll in, and without any published edits available, coding specialists are left to speculate as to why these procedures have been bundled.

One theory, which has been borne out by the experience of at least one provider, is that both codes contain the words submucous resection. Consequently, some carrier representatives are confusing the procedures.

Note: Just below the descriptor for septoplasty, 30520, the CPT manual clearly states: for submucous resection of turbinates, use 30140.

Confusing Similar but Distinct Procedures

Lee Eisenberg, MD, an otolaryngologist in Englewood, N.J., and a member of CPTs executive committee and editorial panel, says that ClaimCheck, a code editing software used by insurance carriers, reportedly had a panel of experts determine that turbinate surgery is a component of septoplasty, which he says is ridiculous.

Segado speculates that some carriers may consider the procedures inclusive because the indications for both are similar. Because a septoplasty typically is performed to correct a deformity in the partition between both sides of the nose, and turbinectomy is the removal of an abnormally enlarged turbinate, Both procedures are performed to improve breathing, Segado says, adding that this does not in any way mean the procedures should be bundled.

There also are continuing difficulties relating to inappropriate bundling of septoplasty and sinus endoscopy and bundles of turbinate procedures with nasal endoscopy, so it is conceivable that carrier coders are confusing similar but entirely distinct procedures and issuing inappropriate denials.

In addition, Segado notes that if the otolaryngologist performs septoplasty, endoscopic sinus surgery and turbinate resection, the middle turbinatesbut not the superior and inferior turbinatesare bundled with the sinus surgery, not the septoplasty. Unfortunately, the CPT codes do not differentiate which turbinates are being resected.

Finally, the fact that septoplasty sometimes is a cosmetic procedure, computerized code editing software will automatically flag the claim for review, says Kathy Zmuda, CPC, lead inpatient coder for CIGNA Healthcare in Scottsdale, Ariz., adding that as a result, the claim will have to be resent manually with accompanying documentation to get reimbursed.

This delays payment of the claim and significantly adds to the workload of coding and/or billing operations in the practice, says Barbara Cobuzzi, MBA, CPC, CPC-H, an independent coding specialist in Lakewood, N.J.

Zmuda, meanwhile, notes that ClaimCheck, probably the most widely used commercial editing software, has had some problems with some of the nasal codes and is in the process of correcting the errors.

Note: More information about bundling of septoplasty and endoscopic sinus surgery is available in the article Successfully Appeal Inappropriate Septoplasty Denial to Gain Reimbursement on page 25 of the April 2000 issue of Otolaryngology Coding Alert, and an article on bundling of turbinectomy and sinus surgery, Documentation Key to Maximizing Sinus Surgery Reimbursement, that appeared on page 1 of the July 1999 issue.

Crosslinking ICD-9 Codes to Procedural Codes

Zmuda agrees that septoplasty and turbinate resection are separately payable as long as the documentation indicates medical necessity and the diagnosis codes correspond to the procedures. She believes that some of these procedures are being denied because the diagnosis codes have not been crosslinked correctly to the appropriate procedure.

Crosslinking means that specific diagnosis codes should be associated with specific procedures on the HCFA 1500 claim form. It is not enough to enter several diagnoses in section 21 of the form above the area where the procedures are listed. After the code(s) are entered in section 21, they receive a number from 1 to 4. (Section 21 only has room for four ICD-9 codes.) The number representing the correct ICD-9 code then is entered in the appropriate box in section 24E, next to the associated procedure code.

For example, an otolaryngologist performing a turbinate resection and septoplasty in the same operative session on a patient with the following ICD-9 codes: 470 (deviated nasal septum) and 478.0 (hypertrophy of nasal turbinates). The 470 is entered in field 1 of Section 21, whereas the 478.0 is entered in field 2.

The septoplasty procedure (30520) is listed at the top of section 24D. Next to it, in section 24E, a 1 should be entered. CPT code 30140 is listed below the 30520, with diagnosis 2 entered in the box to the right (section 24E). (See the example in the shaded box on the previous page.) Only if this is done are the codes properly crosslinked.

Note: Putting both diagnoses in each box in 24E is incorrect and may prompt a review.

To illustrate the importance of crosslinking diagnosis codes, Zmuda ran the 30520 and 30140 through ClaimCheck with two pairs of ICD-9 codes, both crosslinked and unlinked. The first pair of codes used were 470 (deviated nasal septum) and 473.0 (chronic maxillary sinusitis). The second pair was 473.9 (unspecified sinusitis, [chronic]) for the septoplasty and 478.0 (hypertrophy of nasal turbinates) for the turbinate resection. In both cases, the results were the same.

When the procedures ran unlinked to the ICD-9 codes, they came back as bundled. After being linked to the diagnosis codes, ClaimCheck asked for a copy of the op report to prove the septoplasty wasnt a cosmetic procedure, Zmuda says.

She suggests that if the turbinate resection is denied outright, the first thing coders should do is verify that the diagnosis codes were correctly linked to the appropriate CPT codes. If the claim is returned because of the possibility the septoplasty was cosmetic, it should be rebilled with a copy of the op note.

Appealing the Inappropriate Denial

Because of the increasing reports of denials involving these two procedures, coders need to carefully check their explanation of benefits (EOBs) to make sure reimbursement has been forthcoming. In the event of a denial, documentation should be checked carefully and a vigorous appeal should be launched, coding experts agree.

Just because an insurance firm denies something doesnt mean its written in stone or that you have to accept it, Zmuda says, noting that often, the people processing claims for the carrier are not clinically trained, and you may need to quote information to them and tell them where you found it. For example, the appeal should note that These procedures are not bundled in the national Correct Coding Initiative.

Also, submitting documentation that clearly shows that the septum and the turbinates are distinct, separate parts of the nose is useful. A picture or diagram also may help to drive the point home.

To ensure the documentation gets to the person at the carrier who needs to review it, send it by certified mail, Zmuda advises.

As yet, professional organizations such as the AAOHNS have not taken a policy position on this issue. But should you experience a denial, you should forward all pertinent information to the AAO-HNS, Eisenberg says. It was this kind of pressure that prompted ClaimCheck to drop their inappropriate edit of septoplasty and endoscopic sinus surgery, he explains.

Note: For more information on contacting the AAO-HNS, call Eileen Giaimo at 703-519-1566.