Otolaryngology Coding Alert

5 answers ensure you report stereotactic guidance only when you should

If you appropriately bill stereotactic guidance in addition to sinus surgery, you can ethically boost the claim by more than $250. But before you bill 61795, make sure you know the facts about what codes it goes with, its multiple-procedure status, when stereotactic surgery is considered medically necessary, and the elements necessary for proper documentation.

What Codes Can Take a 61795 Add-On?

Code 61795 is an add-on code, meaning you must report it in addition to certain other codes. But identifying which codes you can add it on to may not be right at your fingertips. Usually, the CPT manual lists codes that the add-on code connects to, says Edwina Sprow, CPC, managing partner, Sprow Consulting Services, a division of AskLeslie.net, in Arizona and Texas. -But 61795 doesn-t.-

Answer: You can report planning for stereotactic guidance (+61795, Stereotactic computer-assisted volumetric [navigational] procedure, intracranial, extracranial, or spinal [list separately in addition to code for primary procedure]) in addition to functional endoscopic sinus surgery (FESS) codes 31255-31288, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J. The stereotaxis code includes:

- loading CT scans into a computer
- determining placement of sensors and coordinates
- measurement of the AP-PC line and angle calculations
- placement of the head frame, which you should not separately bill with 20660 (Application of cranial tongs, caliper, or stereotactic frame, including removal [separate procedure]).

Can I Always Report 61795 With 31255-31288?

-Not every FESS requires 61795,- says Claudia Stephens, CPC, at ENT for Children PA in Coppell, Texas. If stereotactic guidance is the standard of care, bundling issues could occur. Insurers may question why 61795 should be separately payable.

Best practice: You should greenlight 61795 only when guidance is medically necessary. Insurance carriers have specific requirements for reimbursing sinus cases performed by this method, says Chasity Heisner, coder for Douglas W. Halliday, PhD, MD, PC, in Syracuse, N.Y. The American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) states that the documentation must include these indications for stereotactic use:

- disease abutting the skull base, orbit, optic nerve or carotid artery 
- cerebrospinal fluid rhinorrhea (349.81) or conditions where there is a skull-base defect
- benign (212.0) and malignant sino-nasal neoplasms 
- revision sinus surgery 
- distorted sinus anatomy of development, postoperative, or traumatic origin 
- extensive sino-nasal polyposis 
- pathology involving the complex posterior ethmoid, frontal and sphenoid sinuses.

Fallback position: If your otolaryngologist wants to use stereotactic guidance more often than the above guidelines allow, give him the thumbs up. But charge 61795 only when the guidance meets medically necessity requirements, Cobuzzi says.

Should I Appeal Denials for Justified 61795s?

Generally, insurers will give you two reasons for denying medically necessary stereotactic guidance. Here's how to fight back with an appeal.

Reason 1: Private payers may deny 61795 claiming that the otolaryngologist is not qualified to bill for the code, or alternatively that the code is reserved for neurosurgeons, Cobuzzi says. In your appeal letter, dispel these falsehoods by explaining:

- CPT 2000 changed the 61795 descriptor to include -extracranial.- -Because that's what ENTs do, they are in fact qualified to use stereotactic guidance and to report 61795,- Cobuzzi says.

- Code 61795 is for planning of stereotactic guidance, not for stereotactic radiosurgery. CPT classifies stereotactic radiosurgery as 61793 (Stereotactic radiosurgery [particle beam, gamma ray or linear accelerator], one or more sessions), which the insurer may limit to neurosurgery.

Reason 2: If a payer denies the stereotactic guidance as a component of the sinus surgery, inform the representative that Medicare no longer bundles 61795 into 31255-31288. The AAO-HNS and the American Rhinologic Society secured reversal of these inappropriate National Correct Coding Initiative edits in 2001.

Should I Expect 61795 to Pay at 50%?

Don't allow payers to treat stereotactic guidance as a multiple procedure. When you bill 61795 in addition to 31255-31288, carriers should not apply a multiple-surgery discount to 61795. Add-on codes by definition are exempt from multiple-procedure payment reductions. 

Example: An otolaryngologist uses stereotactic guidance in addition to a sphenoid frontal endoscopy involving a patient who has chronic frontal and sphenoidal sinusitis. You should report 31276 (Nasal/sinus endoscopy, surgical with frontal sinus exploration, with or without removal of tissue from frontal sinus), 61795 and 31287 (Nasal/sinus endoscopy, surgical, with sphenoidectomy). Link 31276 with 473.1 (Chronic sinusitis; frontal), 31287 to 473.3 (- sphenoidal) and 61795 to both sinusitis diagnoses.

Medicare should pay the stereotactic guidance at 100 percent or about $253.53. The National Physician Fee Schedule assigns 6.69 transitional total relative value units to 61795 (6.69 TTRVU x 37.8975 conversion factor [CF]).

Do, however, expect the carrier to pay the secondary sinus procedure--31287--at 50 percent or at a national rate of $123.55. Code 31287 has 6.52 TTRVU ([6.52 TTRVU x 37.8975 x 0.50); and 31276 has 14.34.

How Often Can I Report 61795 per Session?

You should never bill multiple units of 61795. In other words, you should report stereotactic guidance -only once per surgical session,- Stephens says.

Do not add it onto each service performed in which the physician used the image-guided system. For instance, due to revision surgery, a surgeon uses imaging guidance during an endoscopic anterior and posterior ethmoidectomy and frontal sinus exploration with polyp removal on a patient with chronic frontal and ethmoidal sinusitis. You should report 31276, 31255 (Nasal/sinus endoscopy, surgical; with ethmoidectomy, total [anterior and posterior]) and one unit of 61795, not two. Use 473.1 and 473.2 (- ethmoidal).