Combat Denials of Postoperative Care After Sinus Endoscopy
Published on Thu Jun 01, 2000
It pays for otolaryngologists to have a strategy in place when commercial carriers reject services provided after fiberoptic endoscopic sinus surgery (FESS) procedures. Carriers are denying payment for postoperative service, citing it is part of the FESS global period, even though Medicare has assigned such procedures 0 global days.
Although such denials have been called inappropriate and unreasonable by concerned physician groups, such as the American Academy of Otolaryngologists-Head and Neck Surgeons (AAO-HNS) and the American Rhinologic Society (ARS), select payers still assign a 90-day global period to FESS procedures. Otolaryngology coders should be prepared to deal with such situations if and when they arise.
Some commercial carriers will not pay for post-op care on FESS procedures such as debridement because they assign a global period to the endoscopic sinus procedure, says Barbara Cobuzzi, MBA, CPC, CPC-H, a coding and reimbursement specialist in Lakewood, N.J., who was named 1999 Networker of the Year at the American Academy of Professional Coders annual conference in Minneapolis in May. And when they deny the service, they are in effect implying that charging for postoperative care constitutes unbundling and inappropriate coding.
For example, Cobuzzi notes, an otolaryngologist who performs a bilateral total ethmoidectomy (31255-50) as well as a maxillary antrostomy on the left side (31267-LT), with 0 global days according to Medicare, sees the patient 15 days after surgery for an exam and a debridement. Both services are denied because the commercial insurance carrier has assigned a 90-day global period to the FESS procedure.
The arguments carriers use to justify changing the global period from 0 days to 90 days include:
Services such as postoperative endoscopy and debridement, not to mention visits, amount to little more than a postoperative checkup.
CPT surgery guidelines state that listed surgical procedures include the operation per se ... and normal uncomplicated follow-up care.
Some carriers have used otolaryngology consultants who agree that FESS procedures should have a 90-day global period.
These arguments are vigorously opposed by otolaryngologists and their professional associations, who note three main concerns:
1. CPT guidelines take no position on the length of global packages for individual procedures, and services with 0 global days assigned by Medicare include only normal, uncomplicated follow-up care provided the same day as FESS. Any service provided after the day of surgery is supposed to be paid separately.
2. Postoperative endoscopy and debridement are not checks of past work, they are medically necessary, planned services.
3. Consultants without specific FESS training may be comparing these procedures to older, open sinus procedures that do have a 90-day global period. Such open procedures however, have little in common with FESS, and Laura E. Loeb, J.D., legal counsel for AAO-HNS and ARS, recommends that any physician providing advice to [...]
