Documentation Key to Maximizing Sinus Surgery Reimbursement
Published on Thu Jul 01, 1999
Getting reimbursed correctly for sinosurgery can be difficult. If, for example, an otolaryngologist performs endoscopic sinus surgery on two sinuses, the ethmoidal and the maxillary (31254-31256), some carriers bundle the two procedures together, claiming they are inclusive, even though the Health Care Financing Administration (HCFA) does not bundle them.
The best way around this problem is to use different diagnosis codes for each sinus, says Teresa M. Thompson, CPC, an ENT coding consultant from TM Consulting in Carlsborg, WA. By changing the last digit on the ICD-9 code and applying it to the correct CPT code, the physician makes each diagnosis specific to the individual sinus (473.2, ethmoidal; 473.0, maxillary).
The physician also needs to document the medical necessity of performing both procedures in the operative note, Thompson adds, because if it appears as though the physician removed the maxillary sinus merely to get to the ethmoidal, many commercial carriers will not reimburse the maxillary procedure. She recommends that each procedure be documented individually, and as specifically as possible.
Billing for Bilateral Procedures
According to the 1999 CPT guidelines, if the procedures referred to above were performed bilaterally, the -50 modifier (bilateral procedure) should be attached. However, many insurance carriers are utilizing computer systems that are unable to process bilateral procedures on a one-line item or billing entry. To combat this problem, Thompson recommends billing bilateral procedures on two lines, with the -50 modifier attached to the second claim (see below). Thompson adds that both procedures should be billed at 100 percent, with an expectation of receiving 150 percent for the combined procedure from the carrier. Example two-line entry on claim form:
Box 21: 1. 473.2
Box 24: 31255 1
31255 -50 1
Of course, a patient with severe chronic sinusitis could require work not only on the ethmoidal and maxillary sinuses, but also on the frontal (473.1) and sphenoid (473.3).
There also is a diagnosis code commonly used when two or more sinuses are infected (pansinusitis, 473.8). However, Thompson says, this code does not specify which sinuses are problematic, so it should not be used if the otolaryngologist knows, through the use of an x-ray or CT scan, which sinuses are infected. Instead, the diagnosis codes that are specific to the individual sinuses should be listed on the claim.
Claiming Turbinate Removal Separately
Sinus conditions are often associated with turbinate problems or a deviated septum (470). And, it is not uncommon for the ENT surgeon also to remove the turbinates during sinus surgery or work on sinuses while repairing a deviated septum.
If the physician does remove the turbinate, commercial carriers may bundle it to the sinus procedure(s), saying it cannot be billed separately if the turbinate was removed simply to access the ethmoidal [...]
