Otolaryngology Coding Alert

Coders have dealt with denials of treatments for obstructive sleep apnea for years.

Recently, the American Academy of Otolaryngology -- Head and Neck Surgery sent letters to Wisconsin Physician Services and Anthem Blue Cross regarding their coverage policies for mandibular segmental osteotomy with genioglossus advancement (21199, Osteotomy, mandible, segmental; with genioglossus advancement) when performed to treat obstructive sleep apnea (OSA).

Obstructive sleep apnea (327.23, Organic sleep apnea; obstructive sleep apnea [adult] [pediatric]) describes a blockage of the upper airway that causes the patient to be unable to breathe. One of the ways an ENT can alleviate this potentially life-threatening condition is with genioglossus advancement.

The surgeon creates a small bone window in the front of the lower jaw, and then pulls the tendons that attach the front of the tongue to the jaw forward onto a bone fragment. This creates a larger airway between the back of the tongue and the throat, and results in easier breathing for OSA patients.

"We wrote a letter (to WPS) indicating that it should be covered, and, as a result of the information we provided, they decided to cover it on a case-by-case basis," says Udo Kaja, AAO-HNS's health policy program manager. "We have since written another letter to find out their coverage rationale for the procedure and reiterating that they should cover the procedure; we are waiting for their response."

If you're having trouble getting 21199 paid, check in with AAO-HNS and your state otolaryngology society for backup.

And make sure you've got the right diagnosis. 21199 treats OSA (327.23) and not any of several other sleep disorders, such as central sleep apnea (327.21, Primary central sleep apnea), where the brain forgets to breathe but there are no physical obstructions.

The basics: Obstructive sleep apnea occurs when a patient's airway closes off while he sleeps, causing breathing to stop for at least 10 seconds. Breathing stoppage may last a minute or longer, and may occur as many as hundreds of times during a night.

The hurdle: Many carriers consider genioglossus advancement one of the last treatment options for OSA and allow reimbursement only after more conservative corrections, such as 94660 (Continuous positive airway pressure ventilation [CPAP], initiation and management), have been ineffective.

Before your ENT begins treatment for obstructive sleep apnea, the patient should undergo sleep studies -- most  often with a neurologist, pulmonologist, or otolaryngologist -- to confirm the diagnosis. CMS announced March 3 that it will cover specified sleep tests to confirm the diagnosis in patients who have clinical signs and symptoms of obstructive sleep apnea (327.23). The agency will cover tests your ENT conducts in a sleep laboratory facility.

Your patient must meet certain criteria before you can justify a sleep study by Medicare's and other payers' standards. However, that sleep study is necessary to confirm an OSA diagnosis.

To diagnose OSA, the patient must meet the event threshold on the Apnea-Hypopnea Index or Respiratory Distress Index, says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.

Details: To qualify, a patient must have either 15 or more AHI or RDI events per hour or have between five and 14 AHI or RDI events per hour in addition to documented symptoms of excessive daytime sleepiness (780.53-780.54), impaired cognition (331.83), mood disorders (296.90-296.99) or insomnia (780.52), or documented hypertension (401.0-405.99), ischemic heart disease (410.00-414.9), or history of stroke (V12.59), Pohlig says.

The new policy eliminates the need to collect data for a lengthy portion of the night, as long as you are able to record the minimum number of AHI or RDI events needed to meet the OSA diagnosis threshold in a shorter time frame, explains Pohlig.

Regardless of the monitoring time's length, CMS wants you to document the equivalent of what you would expect to see in a OSA patient over two hours --that is, at least 30 AHI or RDI events or at least 10 of the  same events in addition to the above stated symptoms or conditions.