Otolaryngology Coding Alert

Reimbursement:

Prove Medical Necessity for Nasal Repair Reimbursement

Published on Wed May 10, 2023

Include pre- and postoperative photos to strengthen your case.

When your otolaryngologist performs a nasal repair procedure, such as a rhinoplasty, it may be extremely difficult to obtain payment. Payers are likely to deny the claim as cosmetic unless the diagnosis codes and supporting documentation clearly and unquestionably indicate the procedure was medically necessary. Related procedures, such as septoplasties to correct nasal septal defects or deformities, or nasal vestibular stenosis repair, may also be denied as cosmetic.

That’s why we’ve put together this handy primer to break down what you need to know about medical necessity and the steps to take in order to receive proper and prompt reimbursement for these procedures.

Understand Coverage of Reconstructive vs. Cosmetic

The first step to success with these claims is knowing the difference between cosmetic and functional reconstructive nasal surgeries. The goal of cosmetic surgery is solely to improve appearance in the absence of any signs or symptoms of functional abnormalities, whereas reconstructive nasal surgery is performed to improve nasal respiratory function, correct congenital anatomic abnormalities, repair acquired defects caused by trauma, or treat nasal cutaneous /neoplastic disease.

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, septal repair on an adult with breathing difficulties whose nose was broken years earlier. CPT^®includes three primary rhinoplasty codes:

30400 (Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip)
30410 (Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages, and/ or elevation of nasal tip)
30420 (... including major septal repair)

In addition to denying these procedures as cosmetic, payers may also try to determine the reconstructive versus cosmetic percentage of the procedure and pay accordingly. This is absurd, according to Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, CMCS, of CRN Healthcare Solutions in Tinton Falls, New Jersey, because you can’t do one part of the procedure without the other.

Bottom line: Coverage depends on the purpose of the surgery. For example, Medicare Administrative Contractor (MAC) Palmetto GBA covers rhinoplasty as medically necessary when there is photographic documentation — frontal, lateral, and worm’s eye view images — of the individual’s condition, and the procedure is performed for correction or repair of any of the following:

Nasal deformity secondary to a cleft lip/palate or other congenital craniofacial deformity causing a functional impairment
Chronic, nonseptal, nasal obstruction due to vestibular stenosis (i.e., collapsed internal valves)
Secondary to trauma, disease, congenital defect with nasal airway obstruction (when certain conditions are met)

But when performed solely for the purpose of changing appearance or as a primary treatment for an obstructive sleep disorder when the above criteria for approval have not been met, the MAC does not cover rhinoplasty.

Harvest Site Determines Graft Reporting

Reconstructive surgeries aim to improve function and often involve adding tissue. For example, when rhinoplasty (30400, 30410) is performed to treat restricted airflow in the nasal passages, cartilage or bone grafts are often required to buttress the structure of the nose. In addition, such grafts may require significant additional work compared to cosmetic primary rhinoplasty.

Coding tip: Graft placement is included in the rhinoplasty procedure, but obtaining the graft may be separately coded and payable and should be billed using the appropriate graft code. For bone grafts, use 20900 (Bone graft, any donor area; minor or small …). For cartilage grafts harvested from the ribs, use 20910 (Cartilage graft; costochondral); when harvested from the nasal septum, use 20912 (… nasal septum). If, however, your ENT harvests a graft from the septum and uses it to repair that structure, the harvesting is not separately payable.

Demonstrate Medical Necessity

Otolaryngologists performing a reconstructive rhinoplasty should clearly note why the procedure was medically necessary, preferably in a separate paragraph or section — usually called “findings” or “indications” — of the operative report. It’s important that they document the severity of the symptoms due to the nasal deformities and/or note the impact on health-related quality-of-life issues — difficulty breathing at rest or with exercise, recurrent nosebleeds, acute or chronic sinusitis, snoring and/or sleep apnea.

In the examination documentation, the doctor should note the internal and external nasal anatomy, patency of the nasal passages, and abnormalities such as a deviated septum or turbinate hypertrophy. They should also include an estimate of the percentage of obstruction for each side.

The provider should also note any diagnostic studies performed as clinically indicated, for example, nasal airflow studies, facial imaging, or nasal endoscopy.

In addition, an appropriate ICD-10 code should be cross-linked to the procedure. For rhinoplasty, applicable ICD-10 codes include:

J34.2 (Deviated nasal septum)
J34.89 (Other specified disorders of nose and nasal sinuses)
M95.0 (Acquired deformity of nose)
Q30.8 (Other congenital malformations of nose)
S02.2XX- (Fracture of nasal bones …)
C30.0 (Malignant neoplasm of nasal cavity)

Note, this is not an all-inclusive list. For more information see local coverage article A56587 (www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=56587).

Whenever possible, include pre- and postoperative photographs, as they can be very effective in convincing carriers that a procedure was medically necessary.

Beware When Billing Multiple Procedures

Often, septoplasties are performed during the same session as other repairs, such as for vestibular stenosis (30465). National Correct Coding Initiative (NCCI) edits do not bundle 30465 (Repair of nasal vestibular stenosis …) with septoplasty code 30520 (Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft), so septoplasty should be billable separately from the nasal stenosis repair, though many payers will bundle the procedure as included, according to Lee Eisenberg, MD, an otolaryngologist in Englewood, New Jersey and past member of the CPT^®Editorial Panel.

Note: Septoplasties are usually functional, but may sometimes be performed for cosmetic reasons. As a result, payers scrutinize this procedure, especially when it is performed with other services. Often, claims are denied because the diagnosis has not been correctly crosslinked to the septoplasty, so make sure to link the appropriate ICD-10 code (i.e., J34.2, S02.2XX-) to 30520 on the claim form.

Additionally, otolaryngologists may perform both reconstructive and cosmetic surgeries during the same operative session. When they do, it’s imperative they clearly indicate medical necessity. This means providing precise and accurate documentation that includes an explanation of why each procedure was performed. In their note, the physician “should accurately distinguish which components of the procedure are reconstructive and which are cosmetic. The surgeon should also clearly delineate what percentage of the procedure and fees are reconstructive,” according to guidance by the American Society of Plastic Surgeons.

Make Your Case, Appeal Inappropriate Denials

Even when the correct ICD-10 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 be so low that it barely covers the time and effort involved, Eisenberg advises. Otolaryngologists should explain this to their patients. He recommends billing the patient privately for the rhinoplasty and remitting back to the patient all reimbursement from the payer for any functional repairs.

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