Take This Advice for Accurate Nasal Ablation Coding
Know the major mistakes to avoid. Chronic rhinitis (CR) is persistent inflammation or dysfunction of the nasal mucosa. It is traditionally defined as the presence of at least two nasal symptoms for at least one hour per day and for more than 12 weeks per year. These symptoms include: According to an article published in the Journal of Clinical Medicine, CR “is divided into two primary categories: allergic rhinitis (AR) and nonallergic rhinitis (NAR). However, an additional 30% to 50% of patients with CR may have an overlap of NAR and AR, referred to as mixed rhinitis (MR).” Know CR Treatment Options Assessment of rhinitis by severity, frequency, and exposure can assist the care provider in developing the most appropriate treatment for an individual patient. Establishing the correct diagnosis and identifying the cause of the symptoms are important first steps in selecting appropriate treatment. Initial treatments are based on the patient’s symptoms and may include: However, many patients do not receive adequate symptomatic improvement from medical management alone. This is where nasal ablation comes in. The AMA created two codes for nasal ablation that became effective on January 1, 2024: These codes were established to report nasal/sinus endoscopic destruction of the posterior nasal nerve (PNN) using radiofrequency ablation (31242) or cryoablation (31243). The same conditions support either 31242 or 31243, and code selection is based entirely on the method used. Both procedures can be performed in the physician office or facility setting. Take a Deep Dive Into the PNN Ablation Codes For 31242, the provider uses heat to disrupt nerve signals in the nasal cavity associated with excessive mucus production and nasal congestion. Treatment is delivered in the PNN region in the posterior middle meatus. RhinAer is just one of the commonly recognized radiofrequency systems, but coding is based on the documented procedure, not simply the device’s brand name. This procedure carries a Medically Unlikely Edit (MUE) of “1,” meaning you’ll report 1 unit for the treatment session. The CPT® code descriptor for 31242 represents a bilateral procedure, so you must append modifier 52 (Reduced services) if the physician performs the procedure unilaterally. For 31243, the provider uses cryosurgical ablation to deliver cryogen to the posterior middle meatus and freeze the PNN fibers. This reduces the nerve signals that stimulate the nasal lining. “Clarifix” is a commonly recognized cryotherapy device. Like 31242, this code also carries an MUE of “1.” The code is also a bilateral procedure based on code description, requiring you to append modifier 52 if the physician performs the procedure unilaterally. Another ablation procedure that a provider may use is 30801 (Ablation, soft tissue of inferior turbinates, unilateral or bilateral, any method (eg, electrocautery, radiofrequency ablation, or tissue volume reduction); superficial). Several methods may be used to reduce enlarged inferior turbinate tissue to improve nasal airflow and relieve obstruction. You would report 30801 when treatment is superficial, regardless of the method. Look for This Documentation to Support Coding Complete documentation must identify the procedure performed and support the selected code. You should document the following elements for each type of ablation: For PNN destruction reported with 31242 and 31243, you need to document the following elements: For inferior turbinate ablation reported with 30801, documentation should include the following elements: Avoid anatomical confusion: The physician may approach the PNN region near the posterior inferior turbinate. Therefore, seeing “inferior turbinate” in the procedure note does not automatically support 30801. Instead, look in the documentation to determine whether the provider destroyed enlarged turbinate tissue or treated the posterior nasal nerve region. Then, follow this coding guidance: Other documentation problems can occur when the provider does not identify the method used. Simply stating “ablation” is insufficient to identify the appropriate code. Documentation must identify both the treatment target, which must match the CPT® code descriptor; and, for turbinate ablation, the depth. If this information is not documented, you must submit a provider query. Understand These Common Coding and Billing Issues In addition to paying attention to documentation, you should also take into account the following problems when coding and billing nasal ablation procedures: “RhinAer” or “ClariFix” may help identify the likely modality, but the operative note should always include the procedure, target, approach, and treated sites. Do not assume the procedure code and modality based solely on the device name. Do not separately report a diagnostic nasal endoscopy when it is part of a therapeutic endoscopic procure. According to Chapter 5 of the National Correct Coding Initiative [NCCI] Policy Manual, “When a diagnostic or surgical endoscopy of the respiratory system is performed, it is a standard of practice to evaluate the access regions. A separate HCPCS/CPT code shall not be reported for this evaluation of the access regions.” Make sure you review code descriptors and Medicare bilateral indicators before applying modifier 50 (Bilateral procedure) to any procedure code. Remember, 31242 and 31243 are inherently bilateral. If the physician does not perform the procedure bilaterally, you must append modifier 52. However, the code descriptor for 31801 states “unilateral or bilateral.” This code carries a Medicare bilateral surgery indicator of “2” on the Medicare Physician Fee Schedule, meaning the 150 percent bilateral payment adjustment does not apply because the relative value units (RVUs) already account for performance as a bilateral service. Do not apply modifier 50. Provider documentation must support the diagnosis billed, including specificity. Never assign a diagnosis from a payer policy if it is not supported by the provider’s documentation. Remember: Some payers may not cover these procedures as they may be considered investigational. They may also have specific requirements such as prior authorization. Therefore, you must consult applicable payer guidelines to avoid denials and receive the appropriate payment for the services. Dawnelle Sager, CPC, CPC-I, CPMA, CRC, Professional Fee Coding & Compliance Auditor,
Pinnacle Enterprise Risk Consulting Services
