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.
 

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.
 
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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.
 
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