The ABCs of CPT Coding

CHICAGO-Important aspects of coding and reimbursement for otolaryngologists-head and neck surgeons-including some controversial coding issues-were covered in the American Rhinologic Society (ARS)’s Patient Advocacy Panel here at the 2006 Combined Otolaryngology Spring Meetings (COSM). The panel was moderated by Michael Setzen, MD, Clinical Associate Professor of Otolaryngology at New York University School of Medicine, Chief of the Rhinology Section at North Shore University Hospital at Manhasset (NY), and Chair of the ARS Patient Advocacy Committee. Dr. Setzen introduced the subject by saying, To receive appropriate reimbursement, one must document, show medical necessity, and use proper coding.

Dr. Setzen and two other speakers covered several important coding topics, and here are some highlights from their presentation.

Image Guidance System

The Current Procedural Terminology (CPT) code 61795 is used to reimburse for image guidance systems (IGS), including intracranial, extracranial, or spinal.

Clearly document when and why you used IGS, Dr. Setzen advised. Be specific about when you used it during surgery, and note it in detail in your operation report. If you get denied, send a copy of that report.

Dr. Setzen recommended adhering to the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) guidelines for IGS, because the organization’s policy statement will support your actions. He added that AAO-HNS helped legitimize the use of IGS a year ago. The Academy presented four or five major changes in September 2005 to help us get better reimbursed, he said. These changes include the following statements in the guidelines:

1. IGS is not experimental or investigational.
2. There is sufficient expert consensus opinion and literature evidence to support its use.
3. It is impossible to corroborate this with level one evidence.
4. This technology is used at the discretion of the operating surgeon.
5. The intraoperative use of computer-aided surgery in appropriate select cases is endorsed to assist the surgeon in clarifying complex anatomy during sinus and skull base surgery.

When you are denied, this last statement is very helpful, said Dr. Setzen.

Endoscopic Sinus Debridement

The CPT code 31237 applies to debridement. FESS [functional endoscopic sinus surgery] has zero global days, thus you may begin to report endoscopic debridements the next day, said Dr. Setzen. Just be sure that you document this procedure similar to an operative report in your chart note! He added that you should report unilateral or bilateral codes as appropriate.

Don’t use this if you’re going to ‘clean out the nose’, advised Dr. Setzen. It must be a formal debridement to use this code. And if you’re telling the carrier that you’re using debridement over and above FESS, add on -79 to the 31237 code. Example: You may report debridements following septoplasty or turbinate surgery for FESS, as the debridement is performed for an unrelated diagnosis-use Modifier 79 (31237-79).

For post-op debridement, you need to be reasonable using this, stressed Dr. Setzen. We want to be fair to insurance carriers so that we can continue to be reimbursed.

Balloon Sinuplasty Coding

Clearly document when and why you used IGS. Be specific about when you used it during surgery, and note it in detail in your operation report. If you get denied, send a copy of that report. – -Michael Setzen, MD

This is a controversial issue, said Dr. Setzen. All it is is a technology incorporated into traditional surgery-it’s not a technique. The Academy created a task force that said if you just use balloon technology for a procedure, you should use the code 31299, or the ‘unlisted’ code. He stressed that you must include documentation with this code to get paid, and be very explicit.

Anne H. Burns, CPC, senior coding specialist for the AAO-HNS, covered the next three topics.

Medical Necessity and Explanation of Benefits

Medical necessity, said Ms. Burns, is defined by insurance carriers as providing services which are reasonable and necessary (or appropriate) in light of clinical standards of practice. This definition is linked directly to Local Coverage Determinations (LCDs), which can be found on each carrier’s Web site.

Explanations of benefits are listed at the end of LCDs, and tell you if the claim was denied for medical necessity, financial issues, or administrative issues. (An example of an administrative issue: the patient no longer has that insurance or the service isn’t covered.)

Ms. Burns recommended that you schedule a monthly analysis of denial reasons to get a comprehensive view of why your practice received denials for services provided. It’s important that your staff knows the policies for all your major carriers, she added.

Radiology Coding Issues

Radiology is growing: Imaging services increased 44 percent between 1999 and 2001, with those 65 years old or older using these services twice as much as 45- to 64-year-olds and three times more than 20- to 44-year-olds. As imaging services increase, payers become concerned, which will result in cuts in Centers for Medicare and Medicaid Services payments for these.

Today’s hot topic in imaging is office-based imaging, said Ms. Burns. If you’re doing office-based imaging, you should establish your own list of codes. Don’t just check off a code on your super-bill.

The next three topics were covered by Joseph B. Jacobs, MD, who is Professor of Otolaryngology and Director of Rhinology at New York University Medical Center in New York City and a past President of the ARS.

Modifiers and FESS Coding

Dr. Jacobs pointed out that level 1 modifiers are listed in the American Medical Association CPT manual appendix. These modifiers impact the code description without changing the core meaning, he explained. They also serve to provide additional information regarding the service. The most common modifiers for otolaryngologists include:

Modifier 50: Indicates a similar procedure performed on both the left and right sides during the same surgical session. This is applicable to all endoscopic sinus coding except 31231 (nasal/sinus endoscopy, unilateral or bilateral).

Modifier 51: Indicates more than one surgical service performed by the same physician during the same surgical procedure. Identifies services subject to multiple procedure reductions.

Modifier 58: While not used as often in relation to endoscopic billing, this is applicable to secondary thyroid surgery for malignancy.

Modifier 59: Indicates a procedure or service not normally done together, or a separate incision, excision, or lesion. This code is increasingly being utilized.

Correct Coding Initiative, or CCI, edits are important in bundling and unbundling procedures. Some codes are components of others, said Dr. Jacobs. Don’t use multiple codes together in this case or you will not be paid for all services.

Modifier 79: This unrelated procedure modifier is important with debridement codes. If you append this unbundling modifier, it should allow bypassing or overriding of payer edits.

The code for FESS is usually delineated by side. To receive your full fees for secondary procedures, use modifiers 50, 51, and potentially 59.

Turbinate Issues

There are four major codes for this:

30801 – Cautery/ablation mucosa of turbinates, unilateral or bilateral, any method, separate procedure

30802 – Intramural

30130 – Excision turbinate, partial or complete, any method [resect mucosa]

30140 – Submucous resection turbinate, partial or complete, any method [preserve mucosa]

Carriers use software that automatically bundles these codes with FESS or septal surgery. Your claim may be denied based on same incision or gaining access.

Be very specific about the indicators, warned Dr. Jacobs. You must include all information in your post-op report. If you perform a nasal endoscopy, you must document the reasons. We even include a diagram with our post-op reports.

Comprehensive documentation is key for reimbursement on all coding submitted. In any instance, if your claim is denied, there are actions you can take. You can appeal a denial, said Dr. Setzen. Send a copy of the operative report to the insurance carrier. If you get no response, send it to the commissioner for insurance of your state.

©2006 The Triological Society