Otolaryngology Coding Alert

Use this handy decision tree for accurate billing documentation.

Drug-eluting sinus implants, such as Propel and Sinuva, are vital tools in managing chronic rhinosinusitis and recurrent nasal polyps, especially in postoperative treatment plans after endoscopic sinus surgery (ESS). Historically, both implants were classified under a single HCPCS Level II code; however, on April 1, 2021, the single code was replaced by two specific, product-oriented codes: J7402 (Mometasone furoate sinus implant, (sinuva), 10 micrograms) for Sinuva and S1091 (Stent, non-coronary, temporary, with delivery system (propel)) for Propel.

This change introduced greater complexity into the coding process for both healthcare providers and coders. Proper coding now significantly depends on the care setting and payer policies, involving a careful consideration of both CPT^® and HCPCS Level II codes to ensure accurate billing and reimbursement.

Move Forward With This Propel Advice

Propel implants offer temporary structural support to help maintain the patency of the sinus cavity following surgical procedures while simultaneously delivering targeted anti-inflammatory therapy to promote healing. These bioabsorbable, steroid-eluting implants are produced in three different sizes, allowing practitioners to choose the most suitable option based on the patient’s specific anatomical requirements:

• Propel: Ethmoid sinus
• Propel Mini: Ethmoid sinus and frontal sinus opening
• Propel Contour: Sinus ostia, frontal and maxillary sinuses

The implants are designed to gradually degrade and be absorbed by the body over time, consistently releasing mometasone furoate throughout their dissolution processes. The length of time it takes for the implants to fully dissolve can vary depending on the particular model used, but typically ranges from four to six weeks, supporting a sustained therapeutic effect during this critical healing period. 

Since Propel implants are bioabsorbable, removal procedures are generally unnecessary, as the body naturally integrates them over time. The U.S. Food and Drug Administration (FDA) classifies the product as a medical device and is typically billed under device codes for most payers. However, Medicare requires the use of a J code for billing in the physician’s office setting, since S and C codes are not accepted for professional billing claims.

Increase Your Sinuva Savvy

Sinuva is a corticosteroid-releasing implant intended for adult patients suffering from chronic rhinosinusitis with nasal polyps who have previously undergone ethmoid sinus surgery. It is commonly employed as an alternative to repeated surgical interventions. These implants are typically inserted in an outpatient setting under local anesthesia. The device provides a sustained release of medication over a period of 90 days. Upon completion of therapy, the device is removed. As a drug-led combination product, it is billed using its specific J code.

Understand Medicare and Private Payer Rules

Selecting the appropriate code for the stentsnecessitates identifying the product, the payer, and the place of service. It is essential to review payer instructions to determine which code is required. Correct coding primarily involves using the codes for Sinuva (J7402) and Propel (S1091) along with two other codes: J3490 (Unclassified drugs) and C2625 (Stent, non-coronary, temporary, with delivery system)

Medicare coding requirements for drug-eluting sinus implants vary considerably between professional and facility claims. As Medicare does not recognize S codes and prohibits the use of C codes on physician office claims, coders are required to utilize an unclassified J code when Propel is provided in the office setting, as the table below illustrates:

Medicaid policies vary significantly from state to state, and coding expectations may differ even within the same region. Given the variability and frequent policy updates, verifying coverage and coding rules before implantation is especially important for Medicaid patients. However, Medicare coding for the stents looks like this:

Commercial plans mostly accept the product-specific S code for Propel when billed in either the office or facility setting; however, some require the generic C code for facility claims. Sinuva is generally billed with J7402 regardless of the setting, but certain plans may impose specific documentation or prior authorization requirements. So, you must make sure to review individual policies prior to billing.

Remember These Important Billing Reminders

Because both devices are high-cost items, small errors can result in significant underpayment. Here are some helpful tips for you to keep in mind:

• Watch the units: The descriptor for J7402 defines the unit for the drug as 10 micrograms. A single implant delivers 1350 mg of medication, which equates to 135 units of J7402.

• Know bilateral procedure rules: Be sure to follow payer instructions carefully. Some may require 2 units on two separate lines with right side (RT)/left side (LT) modifiers, while others may accept modifier 50 (Bilateral procedure). 

• Comprehend common payer issues: Payer coverage can vary, so providers should verify medical policies before implantation. Failure to confirm coverage can lead to claim denials and avoidable patient liability. This means paying attention to the following:

• Understand coverage limitations: Some payers allow payment for Sinuva but consider Propel noncovered. It is very important to review payer policies before implantation.
• Understand code selection and unit rules: Refer to payer instructions for code assignment and units, when appropriate.
• Include National Drug Codes (NDCs) on the claim: The 11-digit NDC code is required on the claim form.
• Ensure medical necessity: This means checking payer policy for prerequisites and documentation requirements to support medical necessity.

Accurate and comprehensive documentation is imperative when reporting these services to ensure appropriate code selection. Furthermore, clear documentation is crucial for payer audits to mitigate the risk of claim denials or delays. Proper documentation of the items listed below enhances accurate coding and ensures compliance:  

• Product name (for example, Propel, Propel Mini, Propel Contour, Sinuva)
• Number of implants, laterality
• NDC, lot number, and strength
• Reference to any adverse events or complications if present

Put It All Together With This Coding Decision Tree

The following decision tree offers a step-by-step guide to help you select the correct HCPCS code every time:

• Step 1: Identify the device
  • Propel family or Sinuva
• Step 2: Identify the setting
  • Office or facility
• Step 3: Identify the payer.

Dawnelle Sager, CPC, CPMA, CPC-I, CRC, Professional Fee Coding & Compliance Auditor,
Pinnacle Enterprise Risk Consulting Services (PERCS)