When Non-Covered and Covered Procedures are Performed

When Non-Covered and Covered Procedures are Performed

There are times when a physician will be performing both covered and non-covered procedures at the same operative session. For example, the surgeon may be performing a septoplasty for a deviated septum (J34.2) and nasal obstruction (J34.89), which is a covered service. The patient wants to have a cosmetic rhinoplasty performed at the same time. This is a non-covered service.

Considerations for this case include the following:

  • The facility charges and anesthesia charges need to be divided between the septoplasty and rhinoplasty, with only those associated with the septoplasty going to the insurance company and those associated with the rhinoplasty charged to the patient.
  • Patient privacy would dictate that the details of the cosmetic procedure is none of the insurance company’s business and should not be included in any of the documentation that may have to go to the insurance company.

This means that the surgeon, facility, and anesthesiologist need to keep two sets of documentation, as if this were two different surgical encounters, one for the covered septoplasty and one for the non-covered rhinoplasty. A “Chinese Wall”1 is put up between the covered and non-covered services to virtually separate them in the documentation.

Differentiating Procedures

This is of particular use for the facility and anesthesia charges. Insurance companies are extremely concerned that covered service claims are being used to pay for the facility and anesthesia services of non-covered services when they are performed together. So, should the insurance company find out that both a covered and non-covered service was performed together, the facility and anesthesia records can demonstrate the documentation for each service and that the insurance company was only accountable for the covered service. This adds a layer of compliance to both the documentation and billing for both the facility and anesthesia components.

Similar to the facility and anesthesia documentation, the surgeon’s operative note documentation should treat these services as two serial operative sessions with two operative notes, one for the covered septoplasty and one operative note for the non-covered cosmetic rhinoplasty. Since operative notes usually end with a sentence indicating that “the patient was discharged to recovery”, in this scenario, for the first procedure performed, the operative note will indicate at the end that “the patient was discharged to another procedure”.

By having two separate operative notes, the surgeon insures the privacy of the patient’s cosmetic procedure should the documentation for the covered procedure need to be sent to the insurance company. The documentation for the cosmetic procedure belongs to the patient and the surgeon and since the third-party insurance company is not involved in paying for any part of this procedure, it is not appropriate to share any information about the non-covered service with the insurance company.

Procedures on Both Sides of the Wall

Even though there is a procedure for a septorhinoplasty (30420) and that is what was performed, since the insurance company does not cover the rhinoplasty, the claim to the insurance company includes only 30520 for the septoplasty with ICD-10-CM codes J34.2 for deviated septum and J34.89 for nasal obstruction. The surgeon documented a septoplasty only, supporting 30520 in the operative note that supports the covered service. And the rhinoplasty, 30400 is billed to the patient for the non-covered service with the documentation for the rhinoplasty documented on an entirely separate note.

In the end, there is documentation front to end, from the surgeon, the facility and the anesthesiologist for the septoplasty covered service and there is documentation for the patient pay non-covered service, the rhinoplasty from the surgeon, the facility, and the anesthesiologist.

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1 “Chinese Wall” is a business term describing an information barrier within an organization that was erected to prevent exchanges or communications that could lead to conflicts of interest.

Barbara Cobuzzi

Barbara Cobuzzi

Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, AAPC Fellow, is a consultant with CRN Healthcare Solutions in Tinton Falls, N.J. She is consulting editor for Otolaryngology Coding Alert and has spoken, taught, and consulted widely on coding, reimbursement, compliance, and healthcare-related topics nationally. Barbara also provides litigation support as an expert witness for providers and payers.Cobuzzi is a member of the Monmouth, N.J., AAPC local chapter.
Barbara Cobuzzi

About Has 34 Posts

Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, AAPC Fellow, is a consultant with CRN Healthcare Solutions in Tinton Falls, N.J. She is consulting editor for Otolaryngology Coding Alert and has spoken, taught, and consulted widely on coding, reimbursement, compliance, and healthcare-related topics nationally. Barbara also provides litigation support as an expert witness for providers and payers. Cobuzzi is a member of the Monmouth, N.J., AAPC local chapter.

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