Otolaryngology Coding Alert

Make the most of surgical procedure modifiers when hunting for the right code.

Where conservative treatment has failed, endoscopic transnasal approach for ligation of the sphenopalatine artery may be the surgical technique of choice for control of a severe epistaxis. But did you know that no CPT® code exists specifically for this operative procedure?

Let's say a patient with coagulopathy has epistaxis which has not been controlled with nasal packing. The bleeding originates from the posterior nasal cavity of the posterior ethmoid artery or a branch of the sphenopalatine artery. To control the nose bleed, the otolaryngologist decides to perform an endoscopic transnasal sphenopalatine artery ligation.

When you're left without a definite CPT® code to describe the procedure, you should look at other similar codes, and try to work around it. Let's explore your options with the following codes.

31238: Upgrade Endoscopic Control of Nasal Hemorrhage With Modifier 22

CPT® 2011 guidelines for modifier 22 state, "When the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. Documentation must support the substantial additional work and the reason for the additional work."

For endoscopic transnasal sphenopalatine artery ligation, you may report 31238 (Nasal/sinus endoscopy, surgical; with control of nasal hemorrhage) appended by modifier 22 (Increased procedural service). This ligation procedure involves "interrupting the nasal vasculature at a point distal enough to prevent direct, retrograde, and anastomotic blood flow from the ipsilateral and contralateral carotid systems," as described in the article Endoscopic Ligation of the Sphenopalatine Artery as Primary Management of Severe Posterior Epistaxis in Patients With Coagulopathy by Anand G. Shah, MD; Robert J. Stachler, MD; and John H. Krouse, MD, PhD published in the ENT Journal website (www.entjournal.com/Media/PublicationsArticle/SHAH.pdf).

Disadvantage: Although 31238-22 is a reasonable and accurate coding option, payer reimbursement may be lower than what surgeons feel is consistent with the associated physician work: about $200.46 (5.9 facility RVU, multiplied by the 2011 conversion factor of 33.9764).

Remember: 31238 a surgical endoscopy code. Make sure you pay close attention to how the operative note (OR) describes the endoscopic use.

31299: Go The Safe Way With Unlisted Codes

You may also opt to use unlisted procedure code 31299 (Unlisted procedure, accessory sinuses). Some coders would actually recommend this option, but you should be careful of the glitches:

Majority of the claims don't get paid the first time they are submitted and processed. They require appeal with documentation explaining what was done.

Documentation requirements (paperwork) may prove to be arduous.

Practices are not sure about what charge to attach to the unlisted code. When declaring a charge benchmark, you should choose a relatively close existing code and give justification for its use.

Some experts recommend to use an unlisted code when performing a procedure that has a CPT® code for an open approach but does not have a CPT® code for an endoscopic approach. The reason for this is there is no way to for the RUC (Relative Unit Committee) to account for the relative units associated with this endoscopic approach when and if a new CPT® is created for the endoscopic approach, explains Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J. If the endoscopic approach has been billed with an existing code with a modifier (22 or 52), the RUC committee may be prone to "steal" RVUs from existing CPT® codes allocated to the specialty. If an unlisted code is used, new RVUs will be created when a new code is created, she adds.

Advice: When submitting an unlisted code, ask your physicians to include information at the top of the operative note explaining the procedure and listing a comparable procedure and code for setting reimbursement.

Make a habit of attaching a detailed operative note to your claim since it will be subjected to a strict medical review. Also, a cover letter explaining in lay language what service(s) were performed and the justification for the charge submitted could bail you out of a potential denial or audit.