Pediatric Coding Alert

Get the inside scoop on combating payers' 461.9 rejections

If your insurer denies your E/M claims when you use an "unspecified sinusitis" diagnosis, don't lose hope. Our three expert-recommended 461.9-acceptance tactics can lead you to sinusitis reimbursement.

Pediatric practices that link office visit claims to 461.9 (Acute sinusitis; acute sinusitis, unspecified) report that insurers have recently started denying these claims. But you can obtain E/M payment with 461.9 if you know why payers scrutinize this code and you send documentation to support your claim.

If you've noticed increased denials for 99201-99215 (Office visit for the evaluation and management of a new or established patient ...) with 461.9, you're not alone. "Payers keep denying sinusitis code 461.9 as lacking a fifth digit," says Bobbi Katz, coding specialist at the seven-pediatrician Westfield Pediatrics in Westfield, N.J.

"In California, we're just now receiving sinusitis denials," says Victoria S. Jackson, administrator at Southern Orange County Pediatric Association in Lake Forest. Insurers deny the claims because they want to know which sinusitis type the child has.

Here's what you need to know about each argument -- and what you can do to reverse the cycle of denials.

First, you should challenge payers that deny 461.9 for incomplete digits. "Code 461 doesn't require a fifth digit," Jackson says. Because ICD-9 expands many four-digit codes into five digits each year, some insurers now incorrectly think all diagnostic codes require five digits. But this isn't true.

Tactic: If your insurer sends you missing-digit denials with 461.9, submit a copy of the corresponding page from your ICD-9 manual. "Circle ICD-9's 461.9 directive that shows the code requires a fourth digit," Jackson suggests.

You've heard it a thousand times: ICD-9 requires you to code to the highest specificity possible. Therefore, you should always use the most specific diagnosis possible.

Although that logic applies to diagnoses that your pediatrician can readily make, such as whether otitis serous is acute (381.01, Acute serous otitis media) or chronic (for instance 381.10, Chronic serous otitis media, simple or unspecified), it doesn't hold true with sinusitis. "Children often don't develop sinus cavities until a later age," Jackson says. So a pediatrician often can't make a more definitive diagnosis than unspecified acute sinusitis.

Problem: Insurers want to know the specific sinus cavity affected. "If I submit 461.9 to United HealthCare or Aetna, the payers deny the claim," says Maria M. Torres, CPC, CMM, CCC, CMSCS, a primary-care consultant with Bermudez Medical Consulting Services in Tampa, Fla. "The office visit denial demands that I specify whether the child has maxillary (461.0), frontal (461.1), ethmoidal (461.2) or sphenoidal (461.3) sinusitis."

Sometimes the pediatrician doesn't know which sinusitis type the child has. In some cases, the physician must perform additional diagnostic tests, such as sinus x-rays, to establish a specific diagnosis, Torres says. Alternatively, the pediatrician may refer the child to an otolaryn-gologist to perform further evaluation and determine which cavity is affected. Thus, you don't have a definitive sinusitis diagnosis at the pediatric visit.

Your payer may have backed you into a catch-22 situation: The insurer rejects the unspecified sinusitis code, but the child's cavities aren't developed enough to choose a cavity-related sinusitis code.

Warning: Resist the temptation to submit 461.8 (... other acute sinusitis). Torres unsuccessfully tried this diagnostic alternative.

Using "other acute sinusitis" just triggered a medical-record request. "The term 'other'leaves the door open to the insurer wanting more information on the sinusitis' type," Torres says. And once again, you're at square one because you don't have that information.

To combat the cycle, you should include added ammunition with your appeal. If you know that the insurer will deny 461.9, submit the following documentation after filing the claim.

First, you can solve specific cavity demands with chart notes. Encourage your pediatrician to state, when appropriate, "The child's cavities aren't developed," Jackson says.

In a cover letter, explain that because sinus cavity development usually occurs at a later age than the patient's, the pediatrician cannot make a specific cavity type diagnosis at this time. Therefore, in accordance with CPT, you are submitting an unspecified sinusitis code.

To support your position, include a copy of ICD-9's 461 series with your claim. Inform the payer that ICD-9 lists the attached codes as acceptable sinusitis diagnoses, Jackson says. Therefore, correct coding doesn't require you to choose a specific sinusitis type, but permits an unspecified diagnosis.