Otolaryngology Coding Alert

Otolaryngologists often report difficulties billing turbinate procedures with endoscopic ethmoid sinus surgery. Although these two operations are not bundled in the Correct Coding Initiative (CCI), many carriers do so on the grounds that middle turbinate excision (30130-30140) is incidental to ethmoidectomy (31254-31255) and that CPT code descriptors do not differentiate between middle and inferior turbinates. As a result, it is highly unlikely that carriers will pay separately for turbinate procedures performed merely to access the ethmoids.
 
Many ENTs claim that turbinectomy is a separately identifiable surgical procedure that can improve the outcome of nasal endoscopy. For example, the middle turbinates may be removed not only to access the ethmoids but also to clear an obstructed airway of a hypertrophied turbinate. The procedure can be billed separately if the otolaryngologist clearly documents this medical necessity.
 
Randa Blackwell, financial specialist with the department of otolaryngology at the University of Maryland, reports that many coders are mistaken in believing that a turbinate procedure performed with an ethmoidectomy is automatically included in the ethmoid surgery. "Not all middle turbinectomies are performed to access the ethmoids. With some sinus endoscopies, the turbinates are done last; obviously, the point was not merely access in those cases."
 
Inferior turbinates are not removed simply for access either, she says, adding that these claims are easier to support. However, neither 30130 (Excision turbinate, partial or complete, any method) nor 30140 (Submucous resection turbinate, partial or complete, any method) distinguishes between inferior and middle turbinates. As a result, many carriers routinely include any turbinate excision with an ethmoidectomy and deny the turbinate procedure on first submission, assuming that the codes always refer to middle turbinates. If there is a separate and separately documented reason for the procedure, appending modifier -59 (Distinct procedural service) will facilitate reimbursement.
  
"I always consider the reason for the turbinectomy. If it was to access the ethmoids, I don't bill it. If it was performed to resolve hypertrophy and/or obstruction, I bill it with -59," Blackwell says.
 
A second diagnosis, such as airway obstruction or hypertrophied turbinates, is required to show medical necessity for the turbinectomy and justify its not being considered incidental to the ethmoid surgery, notes Andrew Borden, CPC, CCS-P, CMA, reimbursement manager for the department of otolaryngology at the Medical College of Wisconsin in Milwaukee.
 
Turbinectomies may also be reported separately when performed on the other side of the nose, Borden says. If a turbinectomy is performed on the left side and a partial or total ethmoidectomy is performed on the right side, the turbinectomy should be reported. Depending on the carrier, append either -59 or -LT (Left side)/-RT (Right side) to the appropriate turbinectomy code.
 
If a turbinectomy to access the ethmoid sinus takes more time and effort than usual, Borden recommends appending -22 (Unusual procedural services) to the ethmoidectomy and documenting the additional work.

The concha bullosa is an aerated extension of the middle turbinates; thus, it is often excised (endoscopically or with the rest of the middle turbinates) merely to access the ethmoid sinus.
 
Many carriers will not pay separately for endoscopic removal of this structure (31240, Nasal/sinus endoscopy, surgical; with concha bullosa resection) performed with endoscopic ethmoidectomy on the grounds that it is incidental to the ethmoidectomy and that both procedures involve the same endoscope.
 
On one hand, many otolaryngologists consider the surgeries separate and insist that concha bullosa resections should never be included in the coding for endoscopic ethmoidectomy. Although both procedures are performed through the nasal vestibule, they maintain that two separate incisions (of the ethmoid and concha bullosa) are made and that the second incision adds significant time and complexity to the operating session.
 
On the other hand, carriers maintain that removing the concha bullosa does not require significant additional work or time if a microdebrider is used.
 
Blackwell says that, in the end, the same guidelines should be followed for the concha bullosa removal as for the middle and inferior turbinectomies. If the procedure was performed merely to access the ethmoids, it should not be billed.
 
Note: If a middle turbinectomy is reported, the endoscopic concha bullosa resection should not be billed separately.

The otolaryngologist must clearly document medical necessity when coding turbinectomy or concha bullosa resection for reasons other than access to the ethmoids. "If an airway is obstructed, the otolaryngologist must document the parameters of that obstruction. The obstruction should be noted in the clinical notes of the examination, as well as the operative report when the endoscopic procedures were performed," Blackwell says. The quality of the documentation should match that provided for septoplasties performed during the same session as endoscopic sinus surgery, she adds.
 
"The degree of obstruction caused by hypertrophied turbinates or a concha bullosa should be documented in the otolaryngologist's notes of the visit. Then the procedure can be precertified and billed with modifier -59 appended," Blackwell says. Without supporting documentation, the otolaryngologist will not be able to demonstrate the medical necessity for the turbinate/bullosa procedure. The otolaryngologist's notes must support any attempt to link a separate diagnosis, such as hypertrophy of turbinates or airway obstruction, to the turbinectomy/bullosa resection.