Otolaryngology Coding Alert

Here's the inside scoop on combating payers' 461.9 rejections If your allergy practice is receiving denials for E/M claims with an "unspecified sinusitis" diagnosis, include documentation explaining why this diagnosis is the most accurate choice.

Allergy practices that link office visit claims to 461.9 for acute sinusitis report that insurers have recently started denying these claims. But you can obtain E/M payment with 461.9 if you know why payers scrutinize this code and what you should send to support your claim. Why Insurers Reject 461.9 If you've noticed increased denials for 99201-99215 (Office visit for the evaluation and management of a new or established patient ...) with 461.9 (Acute sinusitis, unspecified), you're not alone. "Payers keep denying sinusitis code 461.9 as lacking a fifth digit," says Bobbi Katz, a coding specialist with a seven-physician practice in Westfield, N.J.

"In California, we're just now receiving sinusitis denials," says Victoria S. Jackson, administrator at Southern Orange County Pediatric Association in Lake Forest. Insurers deny the claims because they want to know which sinusitis type the patient has.

Here's what you need to know about each argument - and what you can do to reverse the cycle of denials. You Don't Need 461.9x First, you should challenge payers that deny 461.9 for incomplete digits. "Code 461 doesn't require a fifth digit," Jackson says. Because ICD-9 expands many four-digit codes into five digits each year, some insurers now incorrectly think all diagnostic codes require five digits. But this isn't true.

Tactic: If your insurer sends you missing-digit denials with 461.9, submit a copy of the corresponding page from your ICD-9 manual. "Circle ICD-9's 461.9 directive that shows the code requires a fourth digit," Jackson says. Unspecified Is OK You've heard it a thousand times: ICD-9 requires you to code to the highest specificity possible. Therefore, you should always use the most specific diagnosis possible.

Although that logic applies to diagnoses that your allergist can readily make, such as whether otitis serous is acute (381.01, Acute serous otitis media) or chronic (for instance 381.10, Chronic serous otitis media, simple or unspecified), it doesn't hold true with sinusitis, particularly if the patient is a child. "Children often don't develop sinus cavities until a later age," Jackson says. So an allergist often can't make a more definitive diagnosis than unspecified acute sinusitis.

Problem: Insurers want to know the specific sinus cavity affected. "If I submit 461.9 to United HealthCare or Aetna, the payers deny the claim," says Maria M. Torres, CPC, CMM, CCC, CMSCS, a primary-care consultant with Bermudez Medical Consulting Services in Tampa, Fla. '"The office visit denial demands that I specify whether the patient has maxillary (461.0), frontal (461.1), ethmoidal (461.2) or sphenoidal (461.3) sinusitis."

Sometimes the allergist doesn't [...]