Otolaryngology Coding Alert

Multiple sinus endoscopies performed during the same operative session are separately billable, but only if the otolaryngologist clearly describes each procedure in the operative report. Similarly, septoplasty and/or submucous resection of turbinates performed during the same operative session must be carefully described in the procedure notes to increase the chances of separate reimbursement for these services.

To optimize payment, the procedures should be listed in order of value, with the procedure with the most relative value units (RVUs) noted first. But, because many private payers (and reportedly, some local Medicare carriers) are incorrectly denying septoplasty and inferior turbinate resection as incidental to endoscopic sinus surgery, otolaryngologists should be prepared to appeal such denials to the highest level, and should demand medical review of the claim by a board-certified otolaryngologist.

The following operative note, which was requested for review by a private carrier after the HCFA 1500 claim form was received, illustrates how the failure to describe accurately and clearly all procedures performed can result in reduced reimbursement. Otolaryngologists also should remember that inadequately noted, billed procedures may be vulnerable to a future audit.

Operative Report

Preoperative diagnosis: nasal septal obstruction, sinusitis
Postoperative diagnosis: same
Procedures: Septoplasty
Bilateral submucous resection of the inferior turbinates
Bilateral endoscopic sinus surgery with bilateral middle meatal osteoplasties
Bilateral anterior-posterior ethmoidectomies
Bilateral frontal recess approach

Procedure/Findings:
With the patient under satisfactory general endotracheal anesthesia, in the supine position, the nose prepared and draped. A left hemitransfixion incision made. Mucoperichondrial and periosteal flaps elevated bilaterally. A good anterior-superior strut of cartilaginous septum was left intact. Badly deviated portions of bone and cartilaginous septum were removed to bring the septum to the midline. Flaps were replaced and sutured.

The left uncinate was infiltrated under 0-degree telescopic guidance. Infundibulotomy performed, sectioning the uncinate with a sickle knife, and removing with a Blakesley forceps. The ostium of the maxillary sinus was located and middle meatal osteoplasty performed with curet and backbiting forceps.

The ethmoids were entered through the bulla ethmoidalis and anterior ethmoidectomy performed, removing polyps throughout. A 30-degree scope was brought into place and the final recess opened with upbiting Blakesley forceps. The posterior ethmoids were entered through the ground lamella, the middle turbinate and the posterior ethmoidectomy performed. The middle meatus filled with Bactroban and Gelfoam.

Attention was turned to the right side of the nose, where an identical anterior-posterior ethmoidectomy, frontal recess approach and middle meatal osteoplasty were performed.

Both inferior turbinates were upfractured, mucous membrane incised, medial and lateral flaps developed. A portion of inferior turbinal bone removed, flaps trimmed and sutured, and the nose packed with rolled Telfa.

Coding the Session

The otolaryngologist billed a private carrier and listed the following procedures in the following order:

31276 nasal/sinus endoscopy, surgical with frontal sinus exploration, [...]