Otolaryngology Coding Alert

With sinus endoscopy surgeries ranking among some of the most common procedures otolaryngologists perform, coders must avoid pitfalls that could cost the practice up to $700 per surgery. So, read the operative report carefully, looking for billable bilateral and distinct procedures to capture the ethical reimbursement to which you're entitled. Note: Reimbursement rates are based on the Medicare Physician Fee Schedule (MPFS) without any geographic adjustments. You may lose more reimbursement from private payers that follow individual fee schedules. Flex Bilateral Power When reading the operative report, you should pay particular attention to which side the otolaryngologist performs functional endoscopic sinus surgery (FESS). The 18 FESS codes (31233-31294) are unilateral, meaning they apply to one side only, says Andrew Borden, CCS-P, CPC, CMA, reimbursement manager for the department of otolaryngology and communication sciences at Medical College of Wisconsin in Milwaukee. Therefore, when the otolaryngologist performs a procedure on one side of the nose and the same procedure on the other side, you should bill the appropriate FESS code using modifier -50 (Bilateral procedure), he recommends. "Report the procedure on two lines with the modifier -50 on the second line, unless your carrier(s) instruct otherwise," Borden says. For example, Medicare and some Blues insist on one line. For instance, if an otolaryngologist performs a partial ethmoidectomy on the right and left side, you should report 31254 (Nasal/sinus endoscopy, surgical; with ethmoidectomy, partial [anterior]) and 31254-50. Or, for single-line reporting, assign 31254-50. Instead of reducing your fee before submitting the claim, allow the payer to adjust the price. Carriers typically pay bilateral procedures at 150 percent of a unilateral procedure. So 31254 performed bilaterally should reimburse at $423.82 (150 percent of $282.55), rather than the unilateral rate of $282.55 (7.68 relative value units x $36.79 conversion factor). If you fail to bill the partial ethmoidectomy bilaterally, your practice will lose $141.27. Different Procedures Matter Now that you've cleared the way for billing bilateral procedures, watch for distinct procedures as well. "Otolaryngologists sometimes perform different endoscopic sinus surgeries on the same sinus on the left and right side," says Barbara Cobuzzi, MBA, CPC, CPC-H, an otolaryngology coding and reimbursement specialist and president of Cash Flow Solutions, a medical billing firm in Lakewood, N.J. In that case, you should report each sinus surgery and append modifier -59 (Distinct procedural service) to the lesser-valued procedure.

Consider an otolaryngologist who performs a partial ethmoidectomy on the right side and a total ethmoidectomy on the left side. You should report both the total ethmoidectomy (31255-LT, with ethmoidectomy, total [anterior and posterior]; left side) and the partial ethmoidectomy (31254-59-RT; right side) appended with modifier -59 to indicate a separate site. Overlooking the partial ethmoidectomy could cost your practice [...]