Otolaryngology Coding Alert

With sinus endoscopy surgeries ranking among some of the most common procedures otolaryngologists perform, coders must avoid pitfalls that could cost the practice up to $700 per surgery. So, read the operative report carefully, looking for billable bilateral and distinct procedures to capture the ethical reimbursement to which you're entitled.

When reading the operative report, you should pay particular attention to which side the otolaryngologist performs functional endoscopic sinus surgery (FESS). The 18 FESS codes (31233-31294) are unilateral, meaning they apply to one side only, says Andrew Borden, CCS-P, CPC, CMA, reimbursement manager for the department of otolaryngology and communication sciences at Medical College of Wisconsin in Milwaukee. Therefore, when the otolaryngologist performs a procedure on one side of the nose and the same procedure on the other side, you should bill the appropriate FESS code using modifier -50 (Bilateral procedure), he recommends. "Report the procedure on two lines with the modifier -50 on the second line, unless your carrier(s) instruct otherwise," Borden says. For example, Medicare and some Blues insist on one line.

For instance, if an otolaryngologist performs a partial ethmoidectomy on the right and left side, you should report 31254 (Nasal/sinus endoscopy, surgical; with ethmoidectomy, partial [anterior]) and 31254-50. Or, for single-line reporting, assign 31254-50. Instead of reducing your fee before submitting the claim, allow the payer to adjust the price.

Carriers typically pay bilateral procedures at 150 percent of a unilateral procedure. So 31254 performed bilaterally should reimburse at $423.82 (150 percent of $282.55), rather than the unilateral rate of $282.55 (7.68 relative value units x $36.79 conversion factor). If you fail to bill the partial ethmoidectomy bilaterally, your practice will lose $141.27.

Now that you've cleared the way for billing bilateral procedures, watch for distinct procedures as well. "Otolaryngologists sometimes perform different endoscopic sinus surgeries on the same sinus on the left and right side," says Barbara Cobuzzi, MBA, CPC, CPC-H, an otolaryngology coding and reimbursement specialist and president of Cash Flow Solutions, a medical billing firm in Lakewood, N.J. In that case, you should report each sinus surgery and append modifier -59 (Distinct procedural service) to the lesser-valued procedure.

Consider an otolaryngologist who performs a partial ethmoidectomy on the right side and a total ethmoidectomy on the left side. You should report both the total ethmoidectomy (31255-LT, with ethmoidectomy, total [anterior and posterior]; left side) and the partial ethmoidectomy (31254-59-RT; right side) appended with modifier -59 to indicate a separate site. Overlooking the partial ethmoidectomy could cost your practice $141.28.

Although overlooking bilateral and distinct procedures can cost hundreds of dollars, forgetting tissue removal can flush an almost equal amount away. Both the maxillary series (31256, Nasal/sinus endoscopy, surgical, with maxillary antrostomy; 31267, with removal of tissue from maxillary sinus) and the sphenoid series (31287, Nasal/sinus endoscopy, surgical, with sphenoidectomy; 31288, with removal of tissue from the sphenoid sinus) contain a code for sinus surgery with and without tissue removal. You should choose the correct code based on whether the operative report documents tissue removal, Borden says. "Documentation should state not only that the surgeon created or enlarged the sinus antrostomy but that he took some type of tissue from inside the sinus cavity." If the otolaryngologist does not remove tissue, use 31256 or 31287. If he or she takes tissue, assign 31267 or 31288.

Reporting a nontissue-removal code rather than a tissue-removal code can sacrifice almost $40 to $130 in revenue. This loss comes from downcoding either the sphenoid or maxillary codes. Coding a sphenoidectomy (31287) when your otolaryngologist performed a sphenoidectomy with tissue removal (31288) will drop reimbursement from $278.50 (31288 has 7.57 RVUs x $36.79) to $238.77 (6.49 RVUs x $36.79), a $39.73 loss. Although this loss may not seem dramatic, if you downcode a maxillectomy with tissue removal (31267) to a maxillectomy (31256), your practice will bill $129.87 less than it deserves.

Another common area for reimbursement loss is image guidance. In revision sinus surgeries, an otolaryn-gologist may employ stereotactic guidance, which helps the surgeon to provide localization of anatomic structures. You should report this add-on service with +61795 (Stereotactic computer assisted volumetric [navigational] procedure, intracranial, extracranial, or spinal [list separately in addition to code for primary procedure]).

Because 61795 is an add-on code, it is not subjected to multiple-procedure rules and should be billed at the full fee. Failing to report the service will cut $255.32 (6.94 RVUs x $36.79) from your practice's pocket.

Billing this service, however, is not automatic. The operative report should clearly state that the otolaryngologist used image guidance. In addition, the American Association of Otolaryngologists-Head and Neck Surgery (AAO-HNS) condones intraoperative use of computer-aided surgery in difficult cases only or instance, with sinus surgery revision or when the findings indicate a specific problem, such as an altered surgical field, extensive sino-nasal polyposis, isolated sphenoid surgery, or benign or malignant sino-nasal neoplasms. "Otolaryngologists use stereotactic guidance primarily for revision sinus surgery and for patients who have had internal landmark changes due to surgery or loss of bony integrity due to neoplasms," Borden says. The physician should document such reasons in the operative report to substantiate using 61795, Borden says.

If you have trouble with payers accepting this service, the AAO-HNS'endorsement may alleviate reimbursement headaches. Include the organization's policy statement available at www.entlink.net/practice/rules/image-guiding.cfm with any appeals for imaging guidance.

Perhaps one of the biggest revenue losses comes from not reporting follow-up services, such as office visits, debridement and endoscopies. The Medicare Physician Fee Schedule indicates zero-day global periods for all FESS procedures, so you should bill for any follow-up services separately starting the day after surgery, Borden says.

Some private carriers, however, reject claims for these services, stating the postprocedure service falls under the global period. Rather than following Medicare's rules, these third-party insurers impose their own 45- or 90-day global periods on the procedures and deny payment.

But with almost $177 at stake for debridement (31237, Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement [separate procedure]) (6.36 RVUs x $36.79), another $36.42 for the office visit (99212-25, Office visit for an established patient; significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) (0.99 RVUs x $36.79), and $116-$210 for the endoscopy (31231, Nasal endoscopy, diagnostic, unilateral or bilateral [separate procedure]) (3.17 RVUs x $36.79) (31233, Nasal/sinus endoscopy, diagnostic with maxillary sinusoscopy [via inferior meatus or canine fossa puncture]) (4.94 RVUs x $36.79) (31235, Nasal/sinus endoscopy, diagnostic with sphenoid sinusoscopy [via puncture of sphenoidal face or cannulation of ostium]) (5.72 RVUs x $36.79), it's worth putting up a fight.

Your practice deserves this payment because the RVUs for the FESS codes do not include these additional services, Borden says. For a payer to base its fee on the RBRVS system and then erroneously add follow-up care into the code is inappropriate. Fight denials with appeals and letters to the state insurance commissioner. Consider dropping payers who refuse to comply when your contracts expire.

Another reimbursement loss comes from undercoding the follow-up endoscopy. For instance, an otolaryngologist inserts an endoscope in the hole that the operation created and checks the maxillary and sphenoid sinuses. Because he forgets to document looking at the sphenoid sinus, the coder reports 31233 instead of 31235, which costs the practice $27.59. If medical necessity exists to look at these areas, make sure to report the code that represents the scope's full extent. And remember to report bilateral procedures for 31233 and 31235; 31231 is the only unilateral FESS code.