Coding: It’s All in the Details

When billing for endoscopic sinus surgery, we recommend that you start with the procedure that has the most value. In the New York area, I usually find that’s a complete ethmoidectomy-so I put that at the top. And then, in descending order, list the procedures with lesser value, he said.

Postop Debridement

Postoperative debridement is another controversial issue. There’s been a little abuse on this-be very, very careful as to how many times you debride, Dr. Setzen said.

On average, four debridements are reasonable, with up to six in complex cases. Document what tissue was removed, which sinuses were entered, which landmarks were preserved, the local anesthetic that was used, and any bleeding or pain. Details should be written up in a separate operative report that is kept in the medical record.

If you do get audited, you’ve at least got good documentation as to what you did, why you did it, and how you did it. It looks like a real little procedure that you did, it’s not just a simple cleaning out of the nose, he said.

Balloon Sinuplasty

There have been problems across the country with coding for balloon sinuplasty. Many carriers consider it experimental and don’t want to cover it, he said. Otolaryngologists, however, are well aware of the advantages of the procedure. It’s catheter-based, it’s minimally invasive, it assists one as a technology to do endoscopic surgery, Dr. Setzen said.

To help battle the resistance to reimbursement, the AAO-HNS Position on Coding for Sinus Balloon Catheterization was published in March 2007. It provides information regarding coding and reimbursement when this technology is used. Otolaryngologists can use this document when appealing denials.

There is one caveat though. The position statement provides two criteria for balloon sinuplasty: one, that a sinus endoscope must be used to position the balloon prior to and during the cannulation of the ostia, and confirming dilation with the balloon; and two, that bone and mucosa be moved in such a way as to significantly enlarge the ostium of the sinus that is treated.

If these two criteria are not met, then you need to use an unlisted code, Dr. Setzen said. A downside of unlisted codes is they generate a lot of paperwork.

Other Coding Issues

Revision ESS is also problematic because there is no CPT code for it. It’s basically the same CPT code as the primary endoscopic procedures. But if you feel it’s over and above the work that you do on a primary procedure, you can append modifier 22, which lets the carrier know that this was unusual service, unusually difficult, Dr. Setzen said.