Otolaryngology Coding Alert

New ABN is essential when rhinoplasty might be cosmetic All rhinoplasty patients undergo the procedure for looks, right? Wrong. Believing this myth could send you searching for a "payable" code when all you really need to get paid is to meet the insurer's condition criteria or obtain a signed financial responsibility statement. One ENT coder was concerned that insurers sometimes consider the rhinoplasty codes cosmetic. So, she wanted to know if another CPT code option existed. "The condition's coverage determination criteria really drive Medicare payment," said Stacie L. Buck, RHIA, CCS-P, LHRM, RCC, in "ABN and Medical Necessity Essentials" presented by audioeducator.com. See if you can unlock the payment door for a rhinoplasty and septoplasty in which the patient had nasal obstruction and septal deviation due to previous trauma. Check if Surgery Meets Coverage Criteria Before proceeding with functional nasal reconstruction, staff should contact the insurer to make sure the procedures are covered, says Ben Willis, biller with Accurate Medical Billing in Tennessee. To get paid for rhinoplasty, you have to find out what criteria you need to meet. For instance, Blue Cross Blue Shield of North Carolina may cover a rhinoplasty: - for deformities of the bony nasal pyramid (nasal bones and nasal process of the maxilla) that: a. directly cause significant and symptomatic airway compromise, sleep apnea, recurrent or chronic rhinosinusitis, and b. are not responsive to appropriate medical management. - Or, for deformity caused by specifically documented trauma within the previous 18 months. Roadblock: When trauma or injury occurred more than 18 months ago, the insurer considers rhinoplasty cosmetic and therefore not covered. The rhinoplasty featured in the case study is medically necessary to alleviate a problem that the patient is having. To indicate medical necessity, get the rhinoplasty preauthorized using 478.1x (Other diseases of nasal cavity and sinuses) and 470 (Deviated nasal septum). Don't forget to add on the trauma diagnosis, such as 905.0 (Late effect of fracture of skull and face bones). Build Your Case Make sure you have rock-solid documentation showing the nasal obstruction and the septal deviation. "Expect to go to battle with your records even for a functional surgery," says Michael Setzen, MD, FACS, FAAP, clinical associate professor in otolaryngology at NYU School of Medicine and section chief of rhinology at North Shore University Hospital in Manhasset, N.Y. You might need to send in copies of the sinus endoscopy and/or sinus CT scan with good documentation showing that medical therapy failed. Blue Cross Blue Shield of North Carolina might request the following documentation: - Preoperative photos must be submitted consisting at a minimum of legible frontal, lateral and columellar views. - Submit complete medical records including patient history, documentation of sleep apnea [...]