Otolaryngology Coding Alert

Question: Our practice is looking to ensure that we have all the appropriate documentation necessary for prior authorization of a balloon sinuplasty procedure. The patient had an in-office computed tomography (CT) scan of the sinuses, but no formal interpretation outside of the review of the performing surgeon. Is this sufficient?

Missouri subscriber

Answer: The answer may vary depending on commercial payer and Medicare Administrative Contractor (MAC). It’s advised that you check with the patient’s payer or MAC prior to scheduling the procedure in order to ensure all prior authorization requirements are met. That’s because some commercial payers, such as BCBS of North Carolina, do in fact have a policy in place that may require an independent radiologist to interpret the CT scan in order to gain authorization. Specifically, their policy states the following:

“Prior to BOD, a CT scan must be performed to document objective evidence of mucosal inflammation of each sinus to be dilated. If an in-office CT scan is performed by the ENT surgeon, an interpretation of the CT scan by an independent radiologist, with documentation of inflammation of each sinus to be dilated, may be required.”

It’s important to note that BCBS of NC underscores the word “may,” which implies that this policy might vary based on circumstance.