Part B Insider (Multispecialty) Coding Alert

Published on Mon Nov 24, 2014 PDF

Yes, you can get paid for 31240 with other procedures. 

If you’re getting denials for 31240 (Nasal/sinus endoscopy, surgical; with concha bullosa resection) when performed during the same patient encounter as 30140 (Submucous resection inferior turbinate, partial or complete, any method) or 30520 (Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft), you’re not alone. Fortunately, a little effort can go a long way when it comes to getting these claims paid – even the 31240 that payers often deny.

Tip 1: Encourage Solid 31240 Note

Your first step toward payment for 31240 is clear documentation of the endoscopic resection of the concha bullosa which is located by the middle turbinate. Explain to the otolaryngologist that describing all the work involved in the added procedure in the operative note will allow you to pinpoint the separate procedure, code for it appropriately and get him or her paid for the procedure.

Benefit: You’ll be able to highlight the work that describes 31240 which is separate from any work related to the septoplasty or any inferior turbinate procedures. In the event of an appeal, solid documentation of 31240 will go a long way in showing the insurer that the endoscopic concha bullosa resection is indeed a separately identifiable procedure. 

Tip 2: Indicate Separate Site With 59  

Before appealing for 31240 payment, try this modifier tactic: Send the initial claim out with a 59 modifier (Distinct procedural service) instead of a 51 (Multiple procedures).

It’s OK: If an insurer places an edit on the concha bullosa code, you can use modifier 59 to indicate that 31240 occurs on a separate site from the septum or the inferior turbinates. The otolaryngologist performs the endoscopic concha bullosa resection on a separate site (the middle turbinate) from the turbinectomy (30130, 30140, inferior) and the septoplasty (30520, the septum). 

Remember: Using modifier 59 may still result in a payment reduction as a result of the second procedure being a multiple procedure. Following multiple- procedure rules, Medicare carriers would pay 31240-51 at 50 percent. You will face the same cut on an additional procedure — even one designated with modifier 59.

Note: With the new “X” modifiers that are being implemented in 2015 to be used instead of the 59 modifier for Medicare, you would use the modifier XS (Separate structure) in this case to indicate that the surgeon performed these procedures at separate sites and that is why they are not bundled. However, since 31240 and 30520,  are not bundled per NCCI and (30140 and 30130) bundle can be overridden with a modifier, you should not have this problem with Medicare carriers. Rather, you will more than likely find these types of denials coming from non-Medicare payers who have put in place their own “proprietary” bundling edits.  

Tip 3: Realize Perseverance Pays Off

Switching from 51 to 59 usually results in 31240 payment for some physicians. 

Caveat: “Don’t just think that changing from a 51 modifier to a 59 in all cases is an acceptable practice when denials are received for bundled pairs, because it is not ok to just add a 59 modifier unless the 59 definition is applicable to the code pair,” warns Barbara J. Cobuzzi, MBA, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J. “In the case of the resection of a concha bullosa and a septoplasty, however, the 59 modifier would be applicable if private payer software has bundled the two codes since the two services represent two different sites. But if we could not support two different sites or different operative encounters, we could not ‘just add’ or ‘just change’ a 51 modifier to a 59 modifier.” 

If changing to modifier 51 doesn’t work for your claim, don’t get discouraged. Instead, have Plan B ready.

What to do: Have an appeal letter ready if the insurer denies 31240-59. Make sure your standard appeal letter is appropriate for the current denial and submit it with a CMS-1500.

Time-saver: Use a standard appeal letter template that requires few modifications. Many coders find that the majority of the times, the insurers do pay.

If they don’t and you have sufficient documentation, just don’t give up. You might even find that you have a decrease in denials once you start sending appeal letters on a regular basis.

Tip 4: Know How to Handle Concha Bullosa Bundles  

Coders sometimes have trouble with some payers bundling 31240 with nasal/sinus endoscopy codes 31255, 31256, and 31267, but the current Correct Coding Initiative (CCI) edits allow you to bill 31240 with any of these procedures. 

Ethmoidectomy and maxillary antrostomies (with or without tissue removal from the sinuses) codes (31254-31267) do not include the work value for concha bullosa resection (31240). Some third-party bundling software, however, does bundle any surgery performed on or near the turbinates (including inferior turbinectomy) with ethmoidectomies and maxillary antrostomies. You should appeal bundles with an important piece of ammunition: documentation of the separate nature of the two different surgeries and that the concha bullosa is located by the middle turbinate, but is not included in the value of each FESS surgery does not include the resection of the concha bullosa. 

Your part: Tell your otolaryngologists that solid documentation can make the difference between 31240 payment on appeal and nonpayment. The surgeon should document the endoscopic excision of the concha bullosa well. The operative note should show all the work involved in the added procedure. 

Expect the payer to subject 31240 to multiple-procedure payment reduction rules, reducing payment by 50 percent when it’s billed as a second procedure. 

Plus: The American Academy of Otolaryngology / Head and Neck Surgery has a letter to assist with appealing denials that you may receive when a payer incorrectly bundles 31240 with other functional FESS surgeries. You can find the letter on the Academy’s website.