Know Your Nose: Coding the Nose and Sinuses

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Barrie Sullivan
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1 Know Your Nose: Coding the Nose and Sinuses Presented by: Melissa Hainz, CPC Date: September 20, 2017 AOA-35 Know Your Nose: Coding the Nose and Sinuses Coding Basics Coding Conundrums Rhinoplasty/Sinus Coding Basics Not all codes are created equal Which structures are the focus? Primary vs. Revision Cleft Lip/Nasal Deformity Septoplasty Other options Sinus 1

Revision = 2 nd+ rhinoplasty 30430 = minor revision (tip) 30435 = intermediate revision (bone) 30450 = major revision (tip and bone) Cleft

2 Which structures? Tip Nasal Valve (Vestibule) Lateral or alar cartilages Bone Nasal bones vs. bony septum Septum Primary vs. Revision Primary = 1 st rhinoplasty = lateral/alar cartilage and/or elevate tip = complete (30400 plus bone) = with septoplasty Revision = 2 nd+ rhinoplasty = minor revision (tip) = intermediate revision (bone) = major revision (tip and bone) Cleft Lip/Nasal Deformity Two options: = tip only = tip, septum, and osteotomies Diagnosis of congenital anomaly (or history of corrected anomaly) must be included 2

3 Septoplasty May include bone: Maxillary crest, vomer, or perpendicular plate of ethmoid Codes: = septoplasty (use with revision rhino) = primary rhinoplasty w/ septoplasty Hx of prior septoplasty only? No impact on rhino code Other Options = Repair vestibular stenosis Spreader graft (most common) Lateral nasal wall recon/strengthen nasal valve Alar batten grafts Lateral crural strut grafts Butterfly grafts Other Options Fracture (acute) = uncomplicated open treatment = complicated w/ fixation 3

$Basics Turbinates/Laterality Inferior 30130 = resection 30140 = submucous resection 30801* = superficial ablation 30802* = intramural ablation 30930 = therapeutic fracture Middle 30999* = per AMA$

4 Sinus Coding Basics Maxillary = w/o tissue = w/ tissue Ethmoid = partial = total Sphenoid = w/o tissue = w/ tissue Frontal Sinuses/Laterality Sinus Coding Basics Turbinates/Laterality Inferior = resection = submucous resection 30801* = superficial ablation 30802* = intramural ablation = therapeutic fracture Middle 30999* = per AMA Superior 30999* = per AMA (rare) *modifier 50 not allowed This isn t a typical patient Cosmetic changes too? Sinus concerns Septal transplant Cancer, fracture, other deformities 4

5 Cosmetic Requests Too? Make clear what is functional and what is cosmetic Focus on structures Use code options for functional portions to your advantage Documentation is key! Sinus Problems Let your Rhinology colleagues be involved Referral system can benefit both divisions Possible more than turbinates causing a problem? FESS/turbinates Rhinologist should document and bill separately Septal Transplant Account for additional work, time and skill Modifier 22 Use on code that includes the septoplasty Include a clear, separate statement explaining procedure, consequences of not performing it, increase in time, etc = nasal septum cartilage graft Bill with appropriate modifier (XU vs. 59) Include comment on CPT Additional statement like mod 22 is helpful 5

6 Non-Traditional Deformities: Watch your Diagnosis Codes Tumor reconstruction Mohs JNA Past fracture/trauma Sequela vs. non-treated vs. malunion) Why can t I get paid? Terminology Insurance Pre-auth process Split case? Back-end process Coding terminology Physician terminology Coding terminology is used by insurances Focus on key words or phrases in coding titles CPT example: Vestibular stenosis vs. Nasal valve collapse Spreader graft most common but other procedures can be used Billing software (EncoderPro, Supercoder) 6

Check each patient s insurance for policies and exclusions Submit accurate/appropriate CPT and dx codes Submit thorough

7 Insurance Rhinoplasty codes considered cosmetic Uphill battle from first visit Bulky insurance policies Continual revisions Don t always make clinical sense Plan exclusions Pre-auth Process Dedicated Managed Care/Coding/Billing team Check each patient s insurance for policies and exclusions Submit accurate/appropriate CPT and dx codes Submit thorough intial eval note and photos with preauth request Non-covered service forms Time/effort on pre-auth is worth more than on back-end 7

8 Split Case? 2 separate reports Same as if two surgeons are involved: Ablative and Reconstructive Rhinoplasty and Sinus Functional and Cosmetic Okay to refer to the alternate report for prep, closure, etc. Only send the functional report to insurance Back-end Process Appeal & follow-up efforts significantly reduced if pre-auth process is efficient and consistent Track denials Catch insurance trends Standardize appeal letters where possible Coding Functional Rhinoplasty Summary Understand your codes Be transparent in your documentation with your operative plan Surround yourself with competent coders and support staff Do the legwork before the patient heads to surgery 8

9 Know Your Nose: Coding the Nose and Sinuses Presented by: Melissa Hainz, CPC Date: September 20, 2017 AOA-35 Coding Functional Rhinoplasty References Slide 4 Images: Slide 7 Image: Slide 10 Image: Slide 11 Image: Slide 19 Images: Encoder Pro 2015 for CPT

MedStar Health considers Septoplasty-Rhinoplasty medically necessary for the following indications:

MedStar Health considers Septoplasty-Rhinoplasty medically necessary for the following indications: MedStar Health, Inc. POLICY AND PROCEDURE MANUAL MP.038.MH Septoplasty-Rhinoplasty This policy applies to the following lines of business: MedStar Employee (Select) MedStar MA DSNP CSNP MedStar CareFirst