Otolaryngology Coding Alert

Caution: You won’t be able to report them until 2016.

The American Medical Association (AMA) released a new round of Category III codes on July 1, with two pertaining to otolaryngologists. Read on for the scoop on these nasal endoscopy codes that could become part of your coding arsenal, effective Jan. 1, 2016. 

Dig Into the Descriptors

The recently-announced codes are as follows:

• 0406T – Nasal endoscopy, surgical, ethmoid sinus; placement of drug eluting implant 

• 0407T -- … with biopsy, polypectomy or debridement.

These codes address the use of PROPEL drug-eluting sinus implants, specifically when the implants are placed in a separate encounter, not at the time of endoscopic sinus surgery.  Therefore, guidelines with the codes instruct that you should not report either 0406T or 0407T with numerous other sinus procedures when the surgeon performs the procedures on the same side. These include:

• 31200 –  Ethmoidectomy; intranasal, anterior

• 31201 – … intranasal, total 

• 31205 – … extranasal, total

• 31231 – Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure)
  

• 31237 – Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement (separate procedure) 

• 31240 – Nasal/sinus endoscopy, surgical; with concha bullosa resection 

• 31254 – Nasal/sinus endoscopy, surgical, with ethmoidectomy, partial (anterior) 

• 31255 – Nasal/sinus endoscopy, surgical, with ethmoidectomy, total (anterior and posterior) 

• 31288 – Nasal/sinus endoscopy, surgical, with sphenoidotomy with removal of tissue from the sphenoid sinus 

• 31290 – Nasal/sinus endoscopy, surgical, with repair of cerebrospinal fluid leak; ethmoid region.

You also will not be able to report 0407T in conjunction with 0406T when the procedures are performed on the same side during the same encounter.

Check the Differences From Other Procedures

Codes 0406T and 0407T represent treatments affecting the ethmoid sinuses, which are just behind the bridge of the nose, between the eyes.

In the procedure of 0406T, the otolaryngologist places a “drug eluting implant” into the ethmoid sinus. During the procedure, the surgeon inserts the device in the sinus cavity using a delivery tool that is included with the implant. The device props open the sinuses and releases an anti-inflammatory medication that reduces polyp formation and promotes healing, then bioabsorbs over 30 to 45 days. Removal typically is not required.

Take note: This is very different from the ethmoidectomies and repairs covered by some other CPT^® codes. These codes also do not apply to the use of other stents, spacers, or packing materials, but only to products approved by the FDA as “drug-eluting sinus implant” (PROPEL is the only one at this time).

When the surgeon performs 0407T, he removes tissue from the ethmoid sinus via biopsy, polypectomy, or debridement. The existing CPT^® codes that represent sinus tissue removal (31267, 31276, and 31288) are for the maxillary, frontal, and sphenoid sinuses. Now you’ll have a more accurate code to report when the ENT does a similar procedure in the ethmoid sinuses.

Watch for Documentation Details

As with any procedure you code, the more detailed your provider’s documentation is, the more accurately you can report the service. Keep these tips in mind when filing your nasal endoscopy claims:

• Verify that the surgeon documented that he used an endoscope. That single detail points you toward the endoscopic sinus codes instead of an open sinusotomy codes (31020-31081).

• Remember endoscopic services have zero global days, while open sinusotomy codes carry 90 global days. You can charge for every service post operative after endoscopic sinus surgery while your surgeon must provide 90 days of no charge post operative care when an open procedure is performed.

• Look for any specifics regarding tissue removed from the sinuses. You must have documentation that the surgeon removed tissue that was more than just mucous (such as a polyp, fungal ball, or some form of mucosa).

Don’t Forget the Purpose of Category III

CPT^® Category III codes are temporary codes that allow data collection for emerging technology, services, and procedures. These codes are intended to be used for data collection to substantiate widespread usage and to determine if the code should “grow up” and become a CPT^® Category I code, or to provide documentation for the Food and Drug Administration (FDA) approval process.

Reimbursement note: Category III codes are not referred to the AMA-Specialty RVS Update Committee (RUC) for valuation because no relative value units (RVUs) are assigned to these codes. Payment for these services or procedures is based on payer policy and not on a yearly fee schedule.

Remember: Submission of Category III coded claims are handled similar to when unlisted codes are used. Describe a similar procedure that this service is like for pricing and submit the documentation to the payer. Each claim will be manually priced and processed. Many private payers will not process Category III codes and expect you to use unlisted codes. So, it is recommended that you check with your payers on their policies.

“It is also important to note that these codes only describe the work associated with placement of the implant,” says Barbara J. Cobuzzi, MBA, CENTC, COC, CPC-P, CPC-I, CPCO, Vice President of Coding and Consulting at J&S Stark Billing and Consulting, Inc., in Shrewsbury, N.J.  “When using these codes (or the endoscopic sinus surgery codes during which the implant is placed concurrently), you must report a HCPCS code for the implant itself.”

Selection of the appropriate HCPCS code is based on the setting of care and payer guidelines. Many payers recommend that you submit S1090 (Mometasone furoate sinus implant, 370 micrograms).  However, since you cannot report S codes to Medicare, CMS specifically instructs providers to use C2625 (Stent noncoronary, temporary, with delivery system) in this situation.

“The problem is, C codes cannot be reported in the office setting, where many sinus surgery procedures are often performed,” Cobuzzi says. “In those cases, J3490 (Unclassified drugs) may be most appropriate.”

Take note: When reporting J3490. Payers might request a description of the product and the NDC code for that product in line 19 of the claim form. Check with the company for the NDC information, and with payers for details regarding their recommended reporting.