Otolaryngology Coding Alert

Details in the surgeon’s notes make all the difference.

As an otolaryngology coder, you know your surgeon performs FESS (functional endoscopic sinus surgery) to restore normal drainage to the sinuses. But do you know how to scour the operative report to ensure you’re submitting every appropriate code? Our experts share four common traps that could be affecting your bottom line or putting you at risk for non-compliance.

Trap 1: Not Reading the Entire Op Note 

Otolaryngologists sometimes do not note the removal of tissue at the top of the operative report, so coders have to read right down to the bottom of the procedure section of the op note to find out they removed maxillary or sphenoid tissue, says Cheryl Odquist, CPC,an otolaryngology reimbursement specialist with California Health Management Billing, a medical management firm in San Diego, California.

The situation can also be reversed. The surgeon might indicate in the operative header that he removed tissue from the maxillary or sphenoid sinuses, yet when you read the op note you learn that he actually did not remove the tissue. 

To avoid such misunderstandings, Odquist recommends that otolaryngologists provide the applicable CPT® codes, such as 31256 (Nasal/sinus endoscopy, surgical, with maxillary antrostomy) or 31287 (Nasal/sinus endoscopy, surgical, with sphenoidectomy). The coder’s function then should be to cross check the codes with the information in the operative note to ensure the physician chose the correct code. 

Documenting codes under a heading such as “Procedures Performed” helps narrow the coding options. But be careful.  

“The listing of the ‘Procedures Performed’ are often out of sync with the actual procedures documented in the body of the operative note,” warns Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J. “Don’t code based on the ‘Procedures Performed’ in the op note header. Rather, code from what is actually documented in the operative note body, describing the actual surgery.”

Note: The operative report also must include the reason(s) for the removal of the tissue.

Trap 2: Incorrectly Reporting the Procedure as Endoscopic 

Before you submit nasal/sinus endoscopy codes (31231-31294), make sure your otolaryngologist performed and documented endoscopic procedures. Auditors report encountering a few cases in which physicians performed sinus procedures via Caldwell-Luc antrotomies or open frontal sinusotomies and not via endoscopy (or at least the otolaryngologist did not document via endoscope). Despite this lack of detail, the coders still used endoscopy codes.

Do this: Reserve the FESS codes (31237-31288) for cases in which the operating room (OR) supports via endoscopy. The Caldwell-Luc (31020-31032) and frontal sinusotomy (31070) require documentation that specifies access through the gums inside the mouth or a trephine (hole) via an incision in the forehead.

Trap 3: Incorrectly Billing for Tissue Removal 

Despite the intent of the physician, if the operative report contains no mention of tissue removal from the sinuses, then you cannot bill 31267 (Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus) or 31288 (Nasal/sinus endoscopy, surgical, with sphenoidotomy; with removal of tissue from the sphenoid sinus). If the operative report simply states nasal endoscopy with antrostomy, even though the surgeon removed tissue to open up the sinus antrum, you can only bill 31256 (Nasal/sinus endoscopy, surgical, with maxillary antrostomy). 

“Removal of mucous and removal of tissue to create the antrostomy (enlarging the opening to the sinus) do not qualify for tissue removal,” Cobuzzi says. “Tissue includes cysts, polyps, mucosa (different than mucous), fungus balls, etc., inside the maxillary sinus or sphenoid sinus to qualify for 31267 and/or 31288, respectively.”

Example: Sometimes the surgeon might note tissue removal at the top of the operative report but not in the description of the procedure, Odquist says. In the body of the op note, the otolaryngologist will state that he or she went into the ostium with the scope, and the sinuses were clear. But if the sinuses are clear, that means there was no tissue to be removed, she says.

Warning: Because most payments are made without the third party insurance company reviewing the op note, there is a good chance that your surgeon might be paid for either 31267 or 31288 despite a lack of supporting documentation in the op note, submitting the codes puts the otolaryngologist at risk for noncompliance if he or she is audited. This would be considered “billing for services not provided,” Cobuzzi points out.

In short, the operative report must show that removal of tissue was a component of nasal/sinus endoscopies. In addition, the summary of the operation performed (at the top of the operative report) also should indicate nasal/sinus endoscopy with removal of tissue as the complete surgical description.

Trap 4: Not Keeping Track of Postoperative Possibilities

When your otolaryngologist sees a FESS patient postoperatively in the office, reporting services can get tricky. The majority of FESS procedures (31237-31288 except 31239) do not have a postoperative global period. 

Keeping that in mind, here’s how to report these visits. 

If your physician sees the patient for an office visit postoperatively for FESS with no other surgeries performed, you should report that visit (99212-99215, Office or other outpatient visit for the evaluation and management of an established patient ...) with no modifier since the surgery performed has zero global days. The same rule applies if you have to bill any other post-operative procedure, such as debridement performed on the patient after his FESS. Submit 31237 (Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement [separate procedure]) performed on the patient after his FESS. 

Although Medicare indicates a zero-day global period for most FESS procedures, codes with zero-day global still include a very small E/M component. Additionally, CCI added a bundle of all established patient E/M procedures with minor procedures in July of 2013. So, 31237 and any established patient E/M service are considered both bundled and a small, minor E/M is considered part of 31237, a zero day minor procedure, by definition of the global package.

When your otolaryngologist documents that an E/M service is significant and separately identifiable from the minor E/M included in debridement (31237) and supports the separate nature required to unbundle the E/M from the debridement, you can apply modifier 25 (Signifi­cant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of a procedure or other service) to the E/M code. 

“It would really help support the -25 modified E/M service if a different diagnosis was assigned to the E/M than what was assigned to the debridement,” Cobuzzi adds.

If the initial surgery included major surgery services, such as a septoplasty (30520, Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft) and/or turbinectomy (30140, Submucous resection inferior turbinate, partial or complete, any method), you’re dealing with an existing global period of 90 days for the sinus surgery. When the ENT debrides the sinus during that post-op global period, append modifier 79 (Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period) to 31237. The debridement is for the sinus, which is totally unrelated to the septoplasty, and/or turbinate work that was done on the septum and/or turbinates which created the 90-day global.