Otolaryngology Coding Alert

Patients who have facial injuries from an accident or who have cancer of the head, neck or face, often require reconstruction procedures. But these procedures are frequently rejected as cosmetic by payers, even though the repair may be a standard procedure that allows skin to heal or fills empty space after the removal of a tumor.

For otolaryngologists who perform reconstructive plastic surgery, this means the medical necessity of the procedures performed needs to be clearly reported. For example, facial wounds and surgical defects that are deep or under tension may require layered repair to get adequate support while healing.

Examples of such procedures include rhinoplasty, mandibular reconstruction, and reconstruction after Mohs surgery, says Gretchen Segado, CPC, an ENT practice coder who works as assistant compliance officer at Thomas Jefferson University in Philadelphia, PA. Often these procedures, among others, are performed for functional rather than cosmetic reasons, she says.

But the coding software used by carriers may automatically edit out plastic surgery procedures without taking into account both the specific nature of the work done in any particular case and the potential future cost to the carrier if the procedure is not performed.

Diagnosis Codes Key to Rhinoplasty

Take rhinoplasty (30400-30462), for example. Although this procedure is often done for cosmetic reasons, it is also performed when there is internal collapse of the nose. The patient may have cancer, or may have been bitten by an animal.

Sometimes, a rhinoplasty may be performed when the physician reshapes a patients deviated septum (30520, septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft) because the patients functional airway is obstructed. In such cases, the septum is usually deformed and the bony pyramid is out of place, so the rhinoplasty is needed to modify the external bony and cartilage structures on the nose and septum. In other words, because the internal and external parts of the nose are related, sometimes it is medically necessary to perform both procedures.

To be properly reimbursed, you must include diagnosis codes that indicate the medical necessity of the procedures. For the example above, the correct diagnosis codes would be 478.1 (other diseases of nasal cavity and sinuses; abscess, necrosis or ulcer of nose [septum]; cyst or mucocele of sinus [nasal]; rhinolith); 738.0 (acquired deformity of nose; deformity of nose [acquired]; overdevelopment of nasal bones); 905.0 (late effect of fracture of skull and face bones); and 784.9 (other symptoms involving head and neck).

She adds that in these cases the pre-certification process is critical. And thorough documentation must be provided by the otolaryngologist to further drive home the medical necessity of the procedure. The documentation can include photographs, which can have a dramatic effect on convincing carriers of the medical necessity of a procedure (for example, in cases where a patients nose has been bitten by an animal).

Note: Nasal tip rhinoplasties (30430, rhinoplasty, secondary; minor revision [small amount of nasal tip work]) are nearly always cosmetic.

Mandibular Reconstruction Often Falls Prey
to Automatic Edits

Another medically necessary procedure that often is denied is mandibular reconstruction (21244, reconstruction of mandible, extraoral, with transosteal bone plate [e.g., mandibular staple bone plate]). The denial for this procedure is due less to issues of medical necessity and more to the automatic edits many carriers have in their reimbursement software, which automatically deny procedures in certain categories, such as dental. Unfortunately, the software is unable to look at the bigger picture, Segado says, and this hurts the carrier as well as the physician.

The procedure, which is often performed on patients with cancers of the palate, is routinely denied by carriers, according to Segado. When this occurs we write the carrier back and explain that this procedure gives these patients a better outcome. It will allow them to swallow, it will help their speech, and improve their quality of life. We also point out the potential cost to the carrier if the procedure is not performed: long-term care, different kinds of feeding, speech pathology services and other assisted devices to enable them to communicate.

Document Carefully After Mohs Surgery

Reconstruction after Mohs surgery offers yet another example of a medically necessary facial plastic surgery procedure. This procedure (17304-17310, chemosurgery [Mohs micrographic technique] including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and complete histopathologic preparation; one of five or more stages with up to five specimens, each stage), is performed to remove ill-defined skin cancers. According to CPT 1999, this procedure requires a single physician to act in two integrated, but separate and distinct capacities: surgeon and pathologist. If either of these responsibilities is delegated to another physician who reports his services separately, these codes are not appropriate. If repair is performed, use separate repair, flap or graft codes.

Although Mohs surgery typically is performed by a dermatologist, ENT physicians will perform the reconstruction to fill the holes in the skin that are left behind. Such repairs (15574, formation of direct or tubed pedicle, with or without transfer; forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands or feet; or 15758, free fascial flap with microvascular anastomosis) may be denied as cosmetic by some carriers, even though they are performed to repair a surgically created defect.

To maximize the chance of being reimbursed for this procedure, the otolaryngologist needs to document carefully. The payer must be informed that the patient had Mohs surgery and be referred to the dermatologist who performed it. The physician also should write a letter explaining that the repairs were medically necessary because the holes in the skin were too large to be left as they were, Segado says.

She adds that Medicare is somewhat more likely to accept diagnosis codes to prove medical necessity for facial plastic surgery procedures. As usual, check with your carrier to find out what they require before billing for such procedures.