If a carrier says there are not enough studies to justify coverage, let them know that the studies cannot be done. However, the AAO-HNS Position Statement for IGS states that IGS is not considered experimental within the profession, and that there is sufficient expert consensus and published studies supporting its use.
Explore This IssueJune 2008
Sometimes carriers don’t want to cover an IGS procedure performed by an otolaryngologist, and say that it would have been eligible if it were performed by a neurosurgeon. The AAO-HNS Guidelines for IGS state that appropriately indicated procedures should be reimbursed regardless of the physician’s specialty. Otolaryngologists can use the guidelines to support what was done.
When coding, you need at least a couple of sentences on what you did…and show the medical necessity as to why you did it, Dr. Setzen said.
If an insurance carrier denies coverage of IGS, appeal it. Send a copy of the operative report to the carrier. If there is no response, send a copy to the commissioner for insurance of the state.
You can also contact the different committees of the Academy, or the sister societies, Dr. Setzen said. For instance, the ARS has a patient advocacy committee that may be able to offer advice and help. Don’t just do one appeal; do repeated appeals because you should be reimbursed, he said. And include a copy of the AAO-HNS Position Statement on IGS.
Endoscopic Sinus Surgery
Endoscopic sinus surgery can also be tricky to code for. Documentation needs to include whether the procedure was open or endoscopic, unilateral or bilateral (CPT codes are unilateral unless otherwise specified), total or partial, and whether or not tissue was removed.
A sinusotomy and diagnostic endoscopy are included in all surgical endoscopies, and gaining access to the surgical site (using the endoscope) is included in the ESS code. One tricky aspect is that an endoscopic resection of a separately identifiable concha bullosa may be coded, but getting paid is difficult, he said.
Also, nasal polypectomy is included in all surgical endoscopies. It is not a separate charge unless it’s done as the only procedure, he said.
Modifiers 59 or 51 should be appended to a functional ESS (FESS) code to indicate the separate sinus; CPT codes differ depending on whether or not there was tissue removal from the maxillary or sphenoid sinus; append modifiers 59 or 51 on turbinate codes if performed at the time of FESS.