How to Appeal Denials When a Medicare Carrier Bundles Inferior Turbinates With Ethmoidectomy
Published on Fri Sep 01, 2000
Some local Medicare carriers are bundling inferior turbinectomies with ethmoidectomies, and coding specialists recommend that if denied, they should be appealed vigorously and reported to the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) whenever they occur.
Even so, until physician groups like the American Medical Association (AMA) and the AAO-HNS can reverse the bundle, attributed by most coding specialists to a black box edit, not all appeals may be successful. One strategy that may be useful in obtaining reimbursement if your Medicare carrier inappropriately is bundling inferior turbinates to ethmoidectomies is to attach modifier -59 (distinct procedural service) to the turbinate removal code.
The edit is believed to be part of a commercial software package similar to GMIS ClaimCheck developed by Atlanta-based HBO&C, which is proprietary and therefore has not been published. Providers can only reason by experience which procedures will not be paid if the edit originates in this so-called black box.
Turbinate Removal Codes
To complicate matters, CPT does not differentiate in its coding between the inferior and middle turbinates. There are three principal turbinate removal codes:
30130 excision turbinate, partial or complete, any method;
30140 submucous resection turbinate, partial or complete, any method; and
30802 cauterization and/or ablation, mucosa of turbinates, unilateral or bilateral, any method (separate procedure) intramural.
These codes are not bundled to 31254 (nasal/sinus endoscopy, surgical; with ethmoid-ectomy, partial [anterior]) and 31255 (nasal/sinus endoscopy, surgical; with ethmoidectomy, total [anterior and posterior]) in Medicares Correct Coding Initiative (CCI).
Until now, there seemed to be an unwritten understanding that the removal of middle turbinates, which is part of the ethmoid complex, was incidental and shouldnt be billed separately when an ethmoidectomy was performed. Inferior turbinates, however, are a different matter. They routinely are not removed during ethmoidectomies, and when they are removed, the reason is not for access, but rather to improve the airway.
If a patient has large turbinates due to an allergy or a large turbinate bone, the size of the turbinate sometimes has to be reduced to improve the airway. For example, if a patient has a right septal dislocation that is obstructed totally, the body, over time, tends to reduce airway size on the left, and the inferior turbinate on the left is likely to enlarge. If a septoplasty (30520, septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft) is performed to move the septum and the size of the enlarged turbinate isnt reduced, the patient likely will have an obstruction in the left nostril.
Therefore, codes 30130, 30140 and 30802 always have been payable separately when performed during the same session as an ethmoidectomy or septoplasty, as long as the [...]
