Health Information Management

The nose knows the importance of correct otolaryngology coding

JustCoding News: Outpatient, March 7, 2012

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Otolaryngology coding covers a wide range of procedures and four parts of the respiratory system—the ears, nose, sinuses, and throat (ENT). Coders commonly use codes in the 20000, 30000, 40000, and 60000 series of CPT® codes. All of that territory provides plenty of opportunities for coding errors.

When coding for otolaryngology procedures, coders need to make sure they read the entire operative report, not just the procedure summary at the beginning because the procedures often differ, says Stephanie Ellis, RN, CPC, owner and president of Ellis Medical Consulting, Inc., in Franklin, TN.

Coders also need a strong understanding of the anatomy when coding otolaryngology procedures. Physicians can perform procedures in a number of sinuses (e.g., sphenoid, frontal, maxillary, and ethmoid), and coders need to understand how to code procedures on each of those sinuses. Coding these procedures correctly is difficult for coders who lack knowledge of ENT anatomy.

When surgeons refer to certain landmarks in their operative notes, coders have to understand the anatomical location of that landmark to determine which sinus the surgeon has entered or exited.

Physicians also need to document which sinus is involved so coders can find the correct code. For example, coders will find a wide range of codes for both diagnostic and surgical nasal/sinus endoscopy procedures (codes 31231–31294), ranging from the most basic diagnostic endoscopy (code 31231) to more complex surgical procedures including:

  • 31254, Nasal/sinus endoscopy, surgical; with ethmoidectomy, partial (anterior)
  • 31276, Nasal/sinus endoscopy, surgical, with frontal sinus exploration, with or without removal of tissue from frontal sinus
  • 31287, Nasal/sinus endoscopy, surgical, with sphenoidotomy
  • 31288, Nasal/sinus endoscopy, surgical, with removal of tissue from the sphenoid sinus
  • 31295, Nasal/sinus endoscopy, surgical; with dilation of maxillary sinus ostium (e.g., balloon dilation), transnasal or via canine fossa

Endoscopic sinus surgery

Coders can run into various trouble spots when coding endoscopic sinus surgeries. For example, coders often miscode maxillary antrostomies by reporting CPT code 31267 (nasal/sinus endoscopy, surgical, with removal of tissue from maxillary sinus) instead of code 31256 (nasal/sinus endoscopy, surgical, with maxillary antrostomy), says Kim Pollock, RN, MBA, CPC, consultant and speaker with Karen Zupko & Associates, Inc., in Chicago.

For coders to report code 31267, the physician must remove “tissue” (e.g., polyps, fungus ball, mucocele) within the maxillary sinus. The physician must remove the tissue from within the maxillary sinus and not around the opening (i.e., ostium), of the maxillary sinus, Pollock says.

Coders also need to be careful when coding the removal nasal polyps, says Pollock. This procedure is included in the surgical codes 31254–31288, and not separately reported.

Balloon sinuplasty procedures

Physicians can use a relatively new procedure called balloon sinuplasty to open inflamed sinuses in patients with chronic sinusitis who have not responded to medication. Physicians can perform the procedure in the office, clinic, or ambulatory surgery center.

In 2011, CPT added these three codes for balloon sinuplasty:

  • 31295, Maxillary sinus balloon dilation endoscopy
  • 31296, Frontal sinus balloon dilation endoscopy
  • 31297, Sphenoid sinus balloon dilation endoscopy

The actual coding for the procedures is easy because the codes are straightforward, Pollock says. The problem is that many payers do not reimburse for these procedures so coders are reluctant to use the ostium balloon dilation codes.

Although the codes are clear-cut, coders can still get tripped up by physician documentation, Ellis says, especially if the coder only reads the summary at the beginning of the operative report.

Coders should look for use of terms such as “dilation” or “displacement” to support the ostium balloon dilation codes, Pollock says. The physician must document soft tissue and/or bone removal, not displacement or dilation, to justify using the usual endoscopic sinus surgery codes 31254–31288.

If the physician performs a balloon dilation in addition to soft tissue and/or bone removal, coders should report only the endoscopic sinus surgery code (31254–31288) and not the dilation code (31295–31297). “You cannot report both the endoscopic surgical code and the balloon code for a procedure on the same sinus,” Pollock says.

Other common coding errors

Tricky otolaryngology coding situations aren’t limited to endoscopic sinus surgery and balloon sinuplasty procedures. Another common error involved billing cautery of the turbinates. Coders should report this procedure using CPT code 30801 (ablation, soft tissue of inferior turbinates, unilateral or bilateral, any method [e.g., electocautery, radiofrequency ablation, or tissue volume reduction]; superficial) or 30802 (ablation, soft tissue of inferior turbinates, unilateral or bilateral, any method [e.g., electocautery, radiofrequency ablation, or tissue volume reduction]; intramural).

Coders commonly use code 30140 for a submucous resection (SMR) instead, says Ellis. Sometimes, this error is because the surgeon’s verbiage at the beginning of the report misleads the coder. The surgeon may call the procedure an SMR even though he or she clearly documented using cautery or radiofrequency, she adds.

Coders who fail to read the entire operative report may also incorrectly report codes for tissue removal by billing codes that do not include tissue removal (e.g., codes 31256 and 31287), Ellis says. In some cases, coders should report a more extensive code (e.g., 31267, 31288) instead.

“Again, this error is because of the surgeon’s verbiage at the beginning of the report throwing the coder off,” Ellis says. “The surgeon just notes said in the summary it was a maxillary antrostomy and didn’t state polyps or tissue was removed.”

Coders should note that it is appropriate to report the tonsillectomy (e.g., code 42826) when the surgeon performs it along with an uvulopalatopharyngoplasty (code 42145) even though a Medicare National Correct Coding Initiative edit bundles the two codes, Pollock says. A CPT Assistant from August 1997 clarifies that this is an appropriate code combination, she adds.

E-mail your questions to Senior Managing Editor Michelle A. Leppert, CPC-A, at mleppert@hcpro.com.



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