Otolaryngology Coding Alert

Many insurance carriers still inappropriately bundle endoscopic sinus procedures with septoplasties. Consequently, otolaryngologists must be prepared to appeal these denials to gain proper reimbursement for their services.

The carriers claim the septoplasty is incidental because it is performed to improve the otolaryngologists access to the sinuses. This view that was bolstered in January 1999 when GMIS ClaimCheck, a commercial software editing package produced by McKesson-HBOC, bundled the two procedures. The edit prompted a storm of protest by otolaryngologists and was removed in November.

Not all carriers have removed the bundle from their software, however, so the procedures still are being denied, and coders need to carefully monitor reimbursement when these two procedures are performed.

Septoplasty Performed for Distinct Medical Reasons

Septoplasties are performed during the same operative session as endoscopic sinus surgery when a patient with sinusitis also has a deviated septum. For example, an otolaryngologist evaluates a patient with chronic sinusitis in the maxillary sinus (473.0) and determines the patient has a deviated septum (470). The otolaryngologist schedules the patient for endoscopic sinus surgery (31267, nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus) and a septoplasty (30520, septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft) to correct the deviated septum, which is creating a nasal obstruction and also may be a contributing factor for the sinusitis.

In this situation, the otolaryngologist likely performs the septoplasty first, because this also will improve access to the maxillary sinus. Some carriers have denied claims on this basis, maintaining that because the septoplasty was performed first and improved access, it is incidental and shouldnt be paid.

This, however, is not the case, according to the American Academy of Otolaryngologists-Head and Neck Surgery (AAO-HNS). When a septal operation is performed at the same time [as endoscopic sinus surgery], it is performed because of unrelated pathology. Most commonly, the septal deformity is blocking the nasal airway and obstructing the patients breathing. This is independent of the sinus pathology and performing the sinus operation alone would be insufficient to correct the pathology. Far less frequently, the septal deformity is impinging onto the turbinates, acting as an etiology contributing to the development of sinus pathology. In such cases, while the sinus pathology itself requires correction, the anatomic deformity of the septum also warrants separate correction so that further sinus pathology does not recur.

In other words, the septoplasty and endoscopic sinus surgery are being performed for distinct medical reasons. But otolaryngologists sometimes inadvertently give carriers ammunition for denying the septoplasty because of the way they write their operative notes, says Barbara Cobuzzi, CPC, CPC-H, CHBME, an independent coding and reimbursement specialist in Lakewood, N.J.

Otolaryngologists get themselves in trouble by explaining why they performed the septoplasty first, Cobuzzi says. They will write that they performed the septoplasty first to gain easier access to the sinus and sometimes not even mention the medical reason for performing the septoplasty, even though they are not required to explain the order of the procedures they perform. In fact, Cobuzzi notes, physicians are not obliged to provide this information to carriers or anyone else.

What should be in the op note, however, is a short explanation of why the septoplasty is medically necessary and a description of the repairs to the nasal septum that were performed. Just saying, Well, in most cases, the deviated septum is obstructing breathing, is not going to cut it, says Susan Callaway-Stradley, CPC, CCS-P, an independent coding and reimbursement specialist in North Augusta, S.C. The carrier needs to know the specific reason the septoplasty was performed. Otolaryngologists need to understand how carriers think. If they start to see septoplasties performed with the great majority of endoscopic sinus surgeries, they will consider it part of sinus surgery and not allow separate billing for the septoplasty, she says.

Cobuzzi concurs. Obviously, the septoplasty must be medically necessary and not performed simply to provide access. She notes that that if every ethmoidectomy has a septoplasty, then fighting to get septoplasties paid in these situations would be much more difficult.

That, however, is not the case, Cobuzzi says, noting that if a septum is deviated to the point that it prevents access to the sinuses, it probably also is contributing to nasal obstruction. Given that, Cobuzzi suggests adding a second diagnosis code (478.1) to indicate nasal obstruction in addition to ICD-9 code 470, which indicates a deviated septum.

Adding the second diagnosis code gives you more ammunition if an appeal needs to be filed, Cobuzzi says. You can point to the fact that you put in the second diagnosis code on the HCFA 1500 claim form when the claim first is filed, not just to buttress your case during the appeal.

Appeal Inappropriate Bundling Edit

Given that the medical reasons for performing endoscopic sinus surgery and septoplasty are distinct, the otolaryngological community understandably may be surprised when commercial carriers bundle the two procedures. The denials are the result of the bundling edit by GMIS ClaimCheck. Carriers use the bundling packages, which are similar to that of Medicares Correct Coding Initiative, to allow their computers to automatically edit claims.

As a result of pressure from AAO-HNS and others, ClaimCheck removed the edit in November 1999. Unfortunately by then, the software package containing the inappropriate edit had been sold to private carriers across the country. From that point on, every carrier who had purchased the package began to edit septoplasty claims if performed at the same session as surgical sinus endoscopy.

Not all carriers who purchased the software with the inappropriate edit have removed it, so the procedures are still bundled by some. Further, even when the edit has been removed, most carriers put the onus on the provider to resubmit inappropriately denied claims and wont perform data searches to help them pay for the claims that were rejected in error. Some carriers even may not inform their providers that inappropriate claims rejections occurred.

Consequently, any providers office that hasnt paid attention to these developments and does not file appeals dating back to January 1999 will lose out, with the carrier pocketing any unclaimed or unappealed revenue.

Filing an Appeal

Regardless of whether the carrier in question has removed the inappropriate edit or still is bundling the two procedures incorrectly, appeals should include the following:

1. Surgical and chart notes to prove that a nasal obstruction prompted the decision to perform the septoplasty and that each procedure was performed to correct a separate functional process.

2. A short note explaining that according to coding guidelines by Medicare and other organizations, such as the AAO-HNS, there is no basis for bundling the two procedures.

3. A reference to the fact that ClaimCheck has deleted the edit from its software because it is inappropriate bundling.

Otolaryngologists also should ensure that any prospective surgery including these two procedures should be precertified. Although precertification concerns medical necessity only and does not guarantee procedures will be paid, it can be useful in an appeal should one of the procedures be denied.

In addition, assuming the septoplasty was performed for the right reasons and documented correctly, otolaryngologists should consider appending modifier -59 ()distinct procedural service)) to the septoplasty code to indicate the procedures were performed on separate sites and therefore should not be bundled, Cobuzzi says. Although modifier -59 is more effective when dealing with Medicare and is not recognized by all private payers, using it appropriately informs the carrier, before the denial and subsequent appeal, that the procedures are distinct and shouldnt be bundled.

Should all avenues of appeal fail, otolaryngologists should take their case to the state department of insurance. In addition, otolaryngologists should contact the AAO-HNS to obtain supporting documentation for an appeal and to enlist their aid in the battle against inappropriate edits.

Use Modifier -79 for Follow-up in the Global Period

Although endoscopic sinus surgery has zero global days, septoplasty has a 90-day global period. This has led some carriers to deny services provided for the sinus surgery during the septoplastys post-op period.

For example, the patient may return three weeks after surgery to have the sinus re-examined or for debridement. Neither service involves the septoplasty and should be reimbursed because the sinus surgery has zero global days. But carriers and providers alike sometimes confuse the procedures. Some providers reportedly even dont claim for the septoplasty just to avoid its 90-day global period in these situations.

To improve reimbursement prospects, modifier -79 ()unrelated procedure or service by the same physician during the postoperative period) should be used to indicate that the postop care for the sinus surgery is unrelated to the septoplasty, says Lee Eisenberg, MD, an otolaryngologist in Englewood, N.J., and a member of CPTs executive committee.

At first glance, billing pre-planned services with modifier -58 ()staged or related procedure or service by the same physician during the postoperative period)may seem more appropriate. Otolaryngologists should remember, however, that the pre-planned or staged service (a debridement, for example) does not relate to the septoplasty (the procedure with the 90-day global) but rather relates to the endoscopy. Therefore, it would be inappropriate to attach modifier -58 because it would imply that the debridement is related to the septoplasty.

Finally, when billing claims during the post-op period, make sure your documentation is in order because the guidelines for billing during a global period are particularly stringent.

Note: Although Medicare requires modifier -79 be used in these situations and will not pay for a procedure or service if it is not attached, other carriers do not require it. Conversely, some private carriers refuse to pay for the procedure or service even if modifier -79 is attached. Therefore, otolaryngologists should contact their carriers to determine how they would like the procedure billed.)