Part B Insider (Multispecialty) Coding Alert

Published on Fri Dec 21, 2012 PDF

You can report 31237 as a post-op procedure

If denials and quickly advised "don’ts" are making you reluctant to code for postoperative endoscopic debridement, gain the confidence to use 31237 by pinpointing the initial surgery and the post-procedure’s reason.

Which Surgery Did the ENT Initially Perform?

An otolaryngologist may perform postoperative debridements (31237, Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement [separate procedure]) for sinusitis after functional endoscopic sinus surgery (FESS, 31254-31294), which may also include septoplasty (30520, Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft) and/or turbinectomy (30130, Excision inferior turbinate, partial or complete, any method, or 30140, Submucous resection inferior turbinate, partial or complete, any method).

Before you can determine if you should report the debridement, you must identify the primary surgery.

Why: The Medicare Physician Fee Schedule assigns different global periods to 30520, 30130-30140 and FESS codes. Codes 30520 and 30130-30140 have 90-day global periods. But FESS codes contain zero global days. Different global periods equate to two coding and reimbursement scenarios .

Scenario 1: The otolaryngologist performs debridement after sinus surgery. A septoplasty was not performed nor was a turbinectomy. Because FESS codes have zero global days, you can bill the medically necessary debridement after endoscopic sinus surgery with 31237. The chart needs to have appropriate documentation that endoscopic debridement was performed and was the focus of the visit, experts say.

Tip: Challenge payers that allege to follow Medicare’s resource-based relative value scale (RBRVS) for their fee schedule but bundle the debridement as included in an insurer-created FESS package. CMS assigned payment values for FESS assuming that medically necessary subsequent diagnostic endoscopies (CPT® code 31231) or surgical endoscopies with debridement (CPT® code 31237) would be reimbursed separately as outside the zero-day global period. Your physician’s documentation must demonstrate the medical necessity as well as the actual procedure in order to support any appeal.

Scenario 2: But when your otolaryngologist performs a debridement within 90 days after septoplasty and/or turbinectomy with or without FESS, the debridement falls within 30520’s and/or 30130-30140’s global surgical periods. Billing the debridement hinges on the answer to another question.

Why Did the ENT Perform Debridement?

Next, you need to focus on what the physician is debriding and why after performing a septoplasty and/or turbinectomy with or without FESS.

Unrelated to septo/turb: When the otolaryngologist performs debridement for a reason that is unrelated to why she worked on the septum and/or turbinates, you should bill for the debridement. Append modifier 79 (Unrelated procedure or service by the same physician during the postoperative period) to 31237 to indicate that the debridement is unrelated to the postoperative period. Modifier 79 can save you from appeals hassles. The documentation must demonstrate that the debridement is unrelated to the septum and/or turbinates and related only to the sinuses.

Also, remember 31237, unlike 31231, is a unilateral code, so you should bill 31237 or 31237-50, depending on whether the surgery was unilateral or bilateral.

Related: But if the debridement is related to the septoplasty/turbinectomy, you should include the related care in the surgery package. For instance, do not bill 31237 for postoperative septo or turbinates, even though the turbinates may require debridement at times. The ENT has already been paid for the post-op visits related to the septo and/or turb procedures because 30520 and/or 30130-30140’s surgical fees include debridements.

Documentation should reflect that the debridement is unrelated to the reason that the otolaryngologist worked on the septum and or turbinates, and it should show medical necessity for the debridement.

Example: After a septoplasty for a deviated septum, a turbinectomy for hypertrophy, a total ethmoidectomy for ethmoidal sinusitis (473.2) and a maxillectomy for maxillary sinusitis (473.0), an otolaryngologist performs debridement. Documentation indicates the debridement was to remove the crusting that occurs following sinus surgery, to prevent infection and to keep the airway patent.

Because the ENT performs the debridement for a reason (chronic ethmoidal and maxillary sinusitis) that is unrelated to the reason for the septoplasty and/or turbinectomy, you should report the debridement.

Append modifier 79 to 31237, and include a note that "the debridement is unrelated to procedures 30520 and/or 30130-30140, diagnosis 470 (Deviated nasal septum) and 478.0 (Hypertrophy of nasal turbinates) on date of surgery xx/xx/xxxx." The diagnosis you should use with the unrelated sinus debridement must be the chronic sinus disease, 473.0 and 473.2.

ICD-10: When your diagnosis system changes in 2014, here are the equivalents to the diagnoses mentioned in this article:

• Code 470 will become J34.2 (Deviated nasal septum).
• Code 473.0 will become J32.0 (Chronic maxillary sinusitis).
• Code 473.2 will become J32.2 (Chronic ethmoidal sinusitis).
• Code 478.0 will become J34.3 (Hypertrophy of nasal turbinates).