Otolaryngology Coding Alert

Question: Aetna denied the following charges: 42831, 30802. The insurer paid for 42831 but not for 30802. The denial letter states, "The turbinates, unilateral or bilateral is commonly performed in conjunction with other procedures as a component of the overall service provided. When performed at the same time as a more complex primary procedures, it is considered clinically integral to the successful outcome of the primary procedure and not indicated for separate reimbursement." We used different diagnoses codes for each procedure.
 
Should we appeal this decision? If so, what documentation do I need and what information can I use to overturn this denial?

Tennessee Subscriber

Answer: Yes, you should fight for turbinate payment. You can try pointing out the following facts to the insurer.
 
1. Inform the payer that the National Correct Coding Initiative (NCCI) doesn't bundle 30802 (Cautery and/or ablation, mucosa of turbinates, unilateral or bilateral, any method [separate procedure]; intramural) into 42831 (Adenoidectomy, primary; age 12 or over).
 
2. Point out that anatomically the turbinates and the adenoids are not located in the same area. The CPT book even lists their respective codes in different sections of the book. You can send pictures showing the different anatomy.
 
3. Emphasize that you used different diagnoses.
 
In your appeal letter, you should also demand a review by a board-certified otolaryngologist.
 
If the payer still denies 30802, you should involve the surgeon, Aetna's medical director, and the AAO-HNS.
 
Don't give up: You should continue pressuring the insurer until the company pays. Some third-party payers, such as Aetna, sometimes don't pay part of the claim until you have filed two appeals. You can usually win with the appropriate documentation if you remain persistent.