Otolaryngology Coding Alert

A little effort can go a long way when it comes to payment for 31240 with 30140 or 30520. That's what one coder found. Take crib notes on what worked at his three-ENT practice.

If you-re getting denials for 31240 (Nasal/sinus endoscopy, surgical; with concha bullosa resection), there are others in your boat.

"An American Rhinology Society (ARS) member is having a problem with 31240 being bundled with 30140 (Submucous resection inferior turbinate, partial or complete, any method) or 30520 (Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft)," says Michael Setzen, MD, FACS, FAAP, Clinical Associate Professor in Otolaryngology at NYU School of Medicine and Section Chief of Rhinology at North Shore University Hospital in Manhasset, N.Y.

"Code 31240 can be reported separately from 30140 and/or 30520," says Ben Willis, billing manager at Accurate Medical Billing LLC in Tennessee.

The Correct Coding Initiative (CCI) does not include 31240 with 30520, 30140 or 30130 (Excision inferior turbinate... ). "Concha bullosa resection (31240) is a separately identifiable service," Willis says. Insurers should reimburse it as such.

Point out to payers that bundle these codes that CMS allows separate reimbursement for them. In the appeal letter, "Remind the insurer that the national guidelines do say that 31240 is separate and can be billed with these codes," Willis says.

Your otolaryngologist must clearly document the endoscopic resection of the middle turbinate's concha bullosa of the middle turbinate, coding experts say. Explain that describing all the work involved in the added procedure in the operative note will allow you to pinpoint the separate procedure and code for it appropriately.

Benefit: You-ll be able to highlight the work that describes 31240. In the event of an appeal, solid 31240 documentation will go a long way in showing the insurer that the endoscopic concha bullosa resection is indeed a separately identifiable procedure.

Before appealing for 31240 payment, try this modifier tactic: "Send the initial claim out with a 59 modifier (Distinct procedural service) instead of a 51 (Multiple procedures)," Willis says.

It's OK: If an insurer places an edit on the concha bullosa code, you can use modifier 59 to indicate 31240 occurs on a separate site. The otolaryngologist performs the endoscopic concha bullosa resection on a separate site (the middle turbinate) from the turbinectomy (30130, 30140, inferior) and the septoplasty (30520, the septum).

Beware: Insurers may not have adjusted their system edits in the wake of CPT 2006's definition change for 30130 (Excision inferior turbinate, partial or complete, any method) and 30140. These codes now specify inferior turbinate. Prior to 2006, the codes could also have represented turbinectomy of the middle turbinate, which is where the concha bullosa is located.

The revised definitions eliminate any overlap between the codes. Concha bullosa resection code 31240 deals with the middle turbinate, and turbinectomy codes 30130 and 30140 deal with the inferior turbinate. Pointing out the definition change could help on appeal.

If a payer has an outdated edit, modifier 59 may appropriately override it. You-re using the modifier as a last resort. The insurer would not accept 31240 with the multiple-procedure modifier. "Modifier 59 reminds the payer that 31240 is a distinct and separate service that deserves payment," Willis says.

Remember: Using 59 may still result in a payment reduction. Following multiple-procedure rules, Medicare carriers would pay 31240-51 at 50 percent or about $83 (4.35 transitional total relative value units x 38.0870 conversion factor = $165.68 x 50 percent). You may face the same cut on an additional procedure -- even one designated with modifier 59.

Switching from 51 to 59 usually results in 31240 payment for Willis- physicians. But if it doesn-t, he's not discouraged. He has plan B ready.

What to do: Have an appeal letter ready if the insurer denies 31240-59, Willis says. "I make sure that my standard appeal letter is appropriate for the current denial and send it off with a CMS-1500."

Time-saver: Use a standard appeal letter that requires few modifications. "The majority of the time, the insurers do pay," Willis says.

If they don't and you have sufficient documentation, don't give up. Willis noted a decrease in denials since he started sending appeal letters. "I do not have to appeal as many."