Here's How to Fight for Turbinectomy Payment With Ethmoidectomy
Published on Tue Aug 09, 2005
Use rock-solid documentation, duel diagnoses and modifier 59 - and appeal those denials
Employing some basic tools will help you obtain inferior-turbinectomy reimbursement on claims containing ethmoidectomy.
Otolaryngology coders frequently have to battle denials for turbinate surgery in addition to ethmoid sinus surgery. While the following steps can't guarantee prompt payment, they'll set the claim up for a solid appeal. Clearly Indicate Which Turbinate You're Billing Documentation must denote that you're requesting inferior-turbinate payment, not middle-turbinate reimbursement. "Because CPT's turbinectomy code doesn't distinguish between inferior and middle turbinates, insurers have no way of telling from the code what site you're charging," says Barbara J. Cobuzzi, president of CRN Healthcare Solutions in Shrewsbury, N.J.
Most insurers bundle the turbinectomy with the ethmoidectomy and assume that you're claiming a middle-turbinate excision. Companies deny 30130 (Excision turbinate, partial or complete, any method) or 30140 (Submucous resection turbinate, partial or complete, any method) with 31254 (Nasal/sinus endoscopy, surgical; with ethmoidectomy, partial [anterior]) and 31255 (...with ethmoidectomy, total [anterior and posterior]) on the grounds that the otolaryngologist either performs the surgeries through the same excision or excises the turbinate to gain entry to the ethmoid.
You should, however, appeal inferior-turbinate denials using documentation that shows the surgeries as distinct procedures. Encourage the otolaryngologist to back his turbinectomy payment with these operative report specifics:
Tip 1: Describe the separate anatomic areas and surgical sites, says Charles F. Koopmann Jr., MD, MHSA, professor and associate chair at the University of Michigan's department of otolaryngology in Ann Arbor. For instance, a note may identify the turbinate and then state "moving to separate surgical area and site (ethmoid air cells)."
"That way, documentation identifies the turbinectomy and ethmoidectomy as separate," Koopmann says.
Tip 2: Identify the exact turbinate that he addresses. "If you omit this information, the insurer will assume the operation involves the middle turbinate," Cobuzzi says.
Use 2 Diagnoses for 30130-30140, 31254-31255 The first way to show insurers that an inferior turbinectomy is a distinct procedure from the ethmoidectomy is to report different ICD-9 codes. Separate diagnoses demonstrate that the turbinectomy is for a separate problem - nasal turbinate hypertrophy - and not just to gain access to the ethmoids, says Bertie Lubinsky, coding specialist at Action Medical Billing Service in Irvine, Calif.
Here's how:
For the turbinectomy (30130-30140), use 478.0 (Hypertrophy of nasal turbinates).
Link the ethmoidectomy (31254-31255) to 473.2 (Chronic ethmoidal sinusitis). Assume insurers will request office notes, as well as the operative report. So make sure documentation supports performing the turbinectomy for breathing problems and the ethmoidectomy for sinusitis. Designate 30130-30140 as a Distinct Procedure If a payer consistently denies 30130 or 30140 because the system assumes the claim involves the middle turbinate, you should also use modifier 59 (Distinct procedural service). [...]
