Otolaryngology Coding Alert

Otolaryngologists often report difficulties billing turbinate procedures with endoscopic ethmoid sinus surgery. Although these two operations are not bundled in the Correct Coding Initiative (CCI), many carriers do so on the grounds that middle turbinate excision (30130-30140) is incidental to ethmoidectomy (31254-31255) and that CPT code descriptors do not differentiate between middle and inferior turbinates. As a result, it is highly unlikely that carriers will pay separately for turbinate procedures performed merely to access the ethmoids.
 
Many ENTs claim that turbinectomy is a separately identifiable surgical procedure that can improve the outcome of nasal endoscopy. For example, the middle turbinates may be removed not only to access the ethmoids but also to clear an obstructed airway of a hypertrophied turbinate. The procedure can be billed separately if the otolaryngologist clearly documents this medical necessity.
 
Randa Blackwell, financial specialist with the department of otolaryngology at the University of Maryland, reports that many coders are mistaken in believing that a turbinate procedure performed with an ethmoidectomy is automatically included in the ethmoid surgery. "Not all middle turbinectomies are performed to access the ethmoids. With some sinus endoscopies, the turbinates are done last; obviously, the point was not merely access in those cases."
 
Inferior turbinates are not removed simply for access either, she says, adding that these claims are easier to support. However, neither 30130 (Excision turbinate, partial or complete, any method) nor 30140 (Submucous resection turbinate, partial or complete, any method) distinguishes between inferior and middle turbinates. As a result, many carriers routinely include any turbinate excision with an ethmoidectomy and deny the turbinate procedure on first submission, assuming that the codes always refer to middle turbinates. If there is a separate and separately documented reason for the procedure, appending modifier -59 (Distinct procedural service) will facilitate reimbursement.
  
"I always consider the reason for the turbinectomy. If it was to access the ethmoids, I don't bill it. If it was performed to resolve hypertrophy and/or obstruction, I bill it with -59," Blackwell says.
 
A second diagnosis, such as airway obstruction or hypertrophied turbinates, is required to show medical necessity for the turbinectomy and justify its not being considered incidental to the ethmoid surgery, notes Andrew Borden, CPC, CCS-P, CMA, reimbursement manager for the department of otolaryngology at the Medical College of Wisconsin in Milwaukee.
 
Turbinectomies may also be reported separately when performed on the other side of the nose, Borden says. If a turbinectomy is performed on the left side and a partial or total ethmoidectomy is performed on the right side, the turbinectomy should be reported. Depending on the carrier, append either -59 or -LT (Left side)/-RT (Right side) to the appropriate turbinectomy code.
 
If a turbinectomy to access the ethmoid sinus takes more time [...]