Avoid Billing Endoscopic Sinusotomies as Open Procedures
Published on Fri Oct 01, 1999
Otolaryngologists could be walking the envelope of fraud in using open sinusotomy codes (31090, sinusotomy, unilateral, three or more paranasal sinuses [frontal, maxillary, ethmoid, sphenoid]) for endoscopic sinus procedures, coding experts warn.
Open codes dont accurately reflect the procedure, and they pay out below the multiple endoscopic sinus theyre often used to replace. The coding shortcut also can close the door to reimbursements for the post-op procedures for 90 days, says Barbara Cobuzzi, MBA, CPC, CHBME, president of Cash Flow Solutions, a physician reimbursement consulting firm in Lakewood, NJ.
Consequences High
The risks of an audit and even accusations of fraud are high. Coding guidelines clearly indicate physicians must use the codes that most accurately describe a procedure. The physician who bills for an open procedure runs the risk that the operative report will disclose the procedure as endoscopic.
The federal penalty for fraudulent Medicare billing can total as much as three times the amount billed, plus thousands of dollars more in damages per incident.
Take, for example, the case of a patient with chronic sinus headache and intermittent green drainage from his nose. His internist has frequently prescribed antibiotics, but now, frustrated by the lack of improvement, sends his patient to the otolaryngologist, who orders a CT scan of the sinus, which shows chronic disease of the ethmoid, sphenoid and maxillary sinuses. In addition, the patient also has a mucocele in the maxillary sinus. The sinus disease and the mucocele are bilateral. So the patient is scheduled for bilateral total endoscopic ethmoidectomies, bilateral sphenoidotomies and bilateral endoscopic maxillary antrostomies with removal of mucocele.
To correctly bill the procedures just described, the coding should be as follows, says Kim Pollock, RN, MBA, an otolaryngology coding and reimbursement specialist in Dallas, TX:
31255: nasal/sinus endoscopy, surgical; with
ethmoidectomy, total [anterior and posterior];
31255-50: bilateral procedure
31267-51: nasal/sinus endoscopy, surgical, with removal of tissue from maxillary sinus
31267-50-51: bilateral procedure
31287-51: nasal/sinus endoscopy, surgical, with sphenoidotomy
31287-50-51: bilateral procedure.
The total number of RVUs billed is 70.28. If the patient is covered by Medicare, the otolaryngologist can expect to be paid for 42.77 RVUs. However, if the otolaryngologist billed the entire procedure with the open 31090 code, the most he could expect from a reimbursement standpoint is 32.81 RVUs.
Clearly, billing 31090 in place of multiple endoscopic sinus procedures is risky and a poor reimbursement strategy. So why would any otolaryngologist use this approach? Coding and reimbursement specialists say that some physicians are taking this drastic step out of frustration with the reimbursement policies of some private payers.
For example, many health insurance carriers now try to bundle maxillary and sphenoid endoscopies to the ethmoid procedure, Cobuzzi [...]
