Question CPT 30520 in POS 11

DawnB2019

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We have been receiving denials from Aetna on CPT 30520 in POS 11. The reason for the denial, per Aetna, is that this is not a valid code/procedure when done in POS 11. We obtained authorization/precert for this, @ POS 11, however they are still denying our claims. Has anyone else had this happen and if so how did you handle it? We have submitted medical records/op reports but they continue to uphold the denial. No other insurance is denying this procedure when done in POS 11, just Aetna.
Any and all help/suggestions appreciated!

Thank you
Dawn Bridges
 

sandra1

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I am very surprised that Aetna is the only insurance denying this procedure. The physician fee schedule does not have any total RVU's associated with non facility so that tells me that the according to the fee schedule it is only payable in a facility setting either POS of 21 or 22.
 

DawnB2019

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I am very surprised that Aetna is the only insurance denying this procedure. The physician fee schedule does not have any total RVU's associated with non facility so that tells me that the according to the fee schedule it is only payable in a facility setting either POS of 21 or 22.
Sandra,
Yes, it is just Aetna however there are both Facility and Non Facility RVU's for CPT 30520. The RVU is the same for POS 22 & 11 (WORK RVU= 7.01, PE RVU=10.02 MP RVU=1.01 TOTAL=18.04 for both Facility and Non Facility). I know that Aetna's denial is incorrect, I was asking the question to see if any other ENT offices were getting the same denials.
 

DawnB2019

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Hi Dawn,
Your surgeon performs septoplasty in an office/procedure room?
Thanks.
Yes, they do. Aetna is the only insurance that is denying this code when done in POS 11. All other insurances, including Medicare pay for it with no issues. Aetna is also starting to deny our surgeries regardless of where they are performed as being experimental/investigation.
 

b.cobuzzi

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Did your doctor perform the Septoplasty using a balloon to align the septum? That is what is usually performed in the office versus what is done in the OR. If only the balloon is used and no incisions are made in order to do the Septoplasty, like the sinus surgeries, you cannot bill the open code, 30520. 30520 means that incisions were made in order to do the Septoplasty. Sometimes a doctor may use the balloon and make incisions and then 30520 can be billed, since incisions are made and used to accomplish the Septoplasty.

But if the septum is straightened with only the balloon, you need to code 30999, unlisted nose procedure and use 30520 in box 19 of your claim for pricing. There was an article on this in either the January or February 2020 Otolaryngology Coding Alert.
 

DawnB2019

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Did your doctor perform the Septoplasty using a balloon to align the septum? That is what is usually performed in the office versus what is done in the OR. If only the balloon is used and no incisions are made in order to do the Septoplasty, like the sinus surgeries, you cannot bill the open code, 30520. 30520 means that incisions were made in order to do the Septoplasty. Sometimes a doctor may use the balloon and make incisions and then 30520 can be billed, since incisions are made and used to accomplish the Septoplasty.

But if the septum is straightened with only the balloon, you need to code 30999, unlisted nose procedure and use 30520 in box 19 of your claim for pricing. There was an article on this in either the January or February 2020 Otolaryngology Coding Alert.
Hello Barbara,
Yes, incisions are made and we do perform them in office (septo's). All other insurance, including Medicare, cover them, however Aetna has been denying them for POS.
 

SharonCollachi

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What does Aetna's policy on it say? Some procedures are only covered in certain places, and getting an authorization for a procedure does not mean it's covered, merely authorized.
 

b.cobuzzi

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I would appeal the denial and include the pre-cert if you have one. I would point out the incisions included in the op note to show that it qualifies for 30520 in the appeal. You can also include the article from Oto Coding Alert that addresses this topic and says that if incisions are made the surgery qualifies for 30520.
 

SharonCollachi

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I would appeal the denial and include the pre-cert if you have one. I would point out the incisions included in the op note to show that it qualifies for 30520 in the appeal. You can also include the article from Oto Coding Alert that addresses this topic and says that if incisions are made the surgery qualifies for 30520.
Barbara, I'm curious (really, not being a smartiepants). Why would you appeal the denial of the code, when the denial is for the place of service? Or are you appealing everything all together? Meaning, they got an auth for that code for that pos, and now Aetna isn't coming thru with payment?

Sharon
 

b.cobuzzi

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It would be dependent on the denial reason, Sharon, don’t you think. (And I do not think you are being a smartiepants, lol).

Although I do throw everything I have at my appeals.
 

b.cobuzzi

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Cheryl, the article was in the February 2020 Otolaryngolgy Coding Alert issue. You need to subscribe to either Supercoder or Oto Coding Alert to get the article. I think it may also be available in AAPC Coder If you select Oto as your specialty. If you are looking for it, search for 30520 and then look at all of the articles that go with that code and you should see the article from the Feb 2020 issue: (I am quoting it here in this response)
Get the Full Scoop on Septoplasty Procedures Involving Balloon Dilation
Follow these steps to ensure your unlisted code gets paid.

Being a seasoned otolaryngology coder means you’ve come to expect an operative report for a given surgery to fall within a certain set of confines and parameters. When a surgical report hits your desk that breaks from the traditional mold, your work as a coder can become exponentially more challenging.

These sentiments have been shared by coders in otolaryngology practices whose physicians have begun to incorporate balloon inflation devices into septoplasty procedures. As you’ll see, the use of these devices fundamentally changes the makeup of both the procedure and the coding methodology.

Read further to get the correct handle on the coding methods for septoplasty procedures involving balloon dilation.

Distinguish Between Septoplasties With, Without Incisions

Before getting into any coding considerations, you’ve got to know how exactly a septoplasty with balloon dilation differs from a traditional septoplasty. While the end goal of each procedure amounts to a reconstruction of a deviated septum, the route in which the physician achieves this varies significantly between procedures.

A traditional septoplasty, as described in code 30520 (Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft), involves the trimming, repositioning, or replacing (with grafts) of cartilage and/or bone. The physician achieves this through a series of incisions within the nose.

Keep in mind: “Code 30520 is described as being performed with or without cartilage scoring, but my experience has found that a resection of the cartilage occurs more often than not in addition the excision of the bone,” explains Kimberly Quinlan, CPC, senior medical records coder for the University of Rochester Medical Center’s Department of Otolaryngology in Rochester, New York.

Compare and Contrast Operative Reports

Consider this portion of an operative report for a traditional septoplasty:

  • “A swivel knife was used to excise the deviated portion of quadrangular cartilage. Next, forceps were used to separate the superior and inferior portions of the bony septum posteriorly. Lastly, deviated portions were removed from the maxillary crest using a 4 mm osteotome.”
As you might expect, when you throw a balloon inflation device into the mix, the fundamentals of the surgery change dramatically. That’s in part due to the less invasive nature of a septoplasty with balloon dilation versus a traditional septoplasty. Rather than reconstructing the deviated septum through a series of incisions, the provider realigns the septum using a balloon dilation microfracture technique. Consider this portion of an operative report:

  • “The septoplasty was performed by using the Acclarent RELIEVA TRACT™ Nasal Balloon Dilation System, which was sequentially inserted along the floor of the nose on both sides. The balloon was inflated which medialized the septum by microfracturing the quadrangle cartilage.”
Code Each Service With Confidence

Given the fundamentally distinct surgical techniques, you can understand why the coding mechanics will vary depending on which route your surgeon goes. If you’re operative note aligns with a traditional septoplasty, the coding process is as simple as reporting code 30520. Be sure to note that this code has a bilateral surgery indicator of “0,” meaning that the 150 percent payment adjustment does not apply. Therefore, you will not report modifiers LT (Left Side), RT (Right Side), or 50 (Bilateral Procedure) since the concept of laterality does not apply to the nasal septum.

The coding mechanics become much more complicated for the septoplasty with balloon dilation. In order to report code 30520, an incision into the septal mucosa and subsequent resection of the bone and/or cartilage of the septum must occur. Since the septoplasty with balloon dilation involves a distinctly different approach, involving no incisions, your only option is to submit this service using unlisted code 30999 (Unlisted procedure, nose).

The last piece in the coding puzzle is determining what existing code is most similar to the septoplasty with balloon dilation. Submitting an existing reference code alongside an unlisted code is important for contextual purposes. “It is recommended that you report a comparison code of 31295 [Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); maxillary sinus ostium, transnasal or via canine fossa] if the surgeon uses one balloon,” advises Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, of CRN Healthcare in Tinton Falls, New Jersey. “If the surgeon uses two balloons, you should also equate 30999 to 31295, except with modifier 50 appended,” says Cobuzzi.

To consider: If the surgeon opts to use a balloon in addition to making incisions into the bone and/or cartilage, bill 30520 instead of the unlisted code. Similar to balloon sinus dilation surgeries that also include tissue removal or excision into the maxillary, frontal, or sphenoid sinuses, you’ll report the appropriate functional endoscopic sinus surgery (FESS) code instead of a balloon sinus dilation code.
 
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