Otolaryngology Coding Alert

Question: We recently billed for ESS with an NSR (nasal septum repair). The NSR was listed as inclusive and wasnt paid for. We used codes:

30520 (septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft); ICD-9 code 470 (deviated nasal septum; deflected septum [nasal][acquired]).

31255-51 (nasal/sinus endoscopy, surgical; with ethmoidectomy, partial [anterior]; multiple procedure); ICD-9 code 473.2 (chronic sinusitis, ethmoidal).

31255-50-51 (same as above, bilateral procedure); ICD-9 473.2.

31256-51 (nasal/sinus endoscopy, surgical, with maxillary antrostomy; multiple procedure); ICD-9 code 473.0 (chronic sinusitis, maxillary).

31256-50-51 (same as above, bilateral procedure); (473.0)

31525-51 (laryngoscopy, direct, with or without tracheoscopy; for aspiration; diagnostic, except newborn) ICD-9 784.49 (voice disturbance, other, including
change in voice, dysphonia, hoarseness, hypernasality, hyponasality).

Lucy Loder
Omaha, NE

Answer: Most carriers believe that septoplasties and ethmoidectomies are not commonly performed together, says Kathy Zmuda, CPC, lead inpatient coder with CIGNA Health Plans of Scottsdale, AZ, and when they are, it is usually to gain access to the sinus that is blocked due to a nasal obstruction. The septoplasty is being done to allow for the necessary access, making it a necessary component of the primary procedure.

If there was a nasal obstruction, Zmuda also suggests adding ICD-9 code 478.1 but if you do not agree with what the insurance company paid you always have the right to appeal with a copy of the operative report attached. If there was a nasal obstruction you might also try using ICD-9 478.1 (other diseases of upper respiratory tract; other diseases of nasal cavity and sinuses).

Barbara Cobuzzi, MBA, CPC, agrees that if the septoplasty is for access only, it should not necessarily be paid. But when that is the case, she says, the deviated septum would likely be blocking the airway and therefore be a source of obstruction. Isnt that what ICD-9 470, deviated septum, means? I would appeal and fight any septoplasty not paid with endoscopic sinus surgery as long as the doctor indicated the obstruction in the op note and it does not say that the septoplasty was done only for access, Cobuzzi says.

I would teach ENT doctors to make sure their dictation supports the medical necessity of the septoplasty, not just access.

Cobuzzi adds that most payers only look at the first diagnosis, so even if 478.1 was used, it might not be considered. I wouldnt be surprised if the septoplasty is bundled with the ESS surgeries in the commercial software edit package, with which we have seen consistent improper edits, she says.