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Coding & Billing
ENT Surgery Coding Pointers
Lolita Jones
Publish Date: May 13, 2008   |  Tags:   Financial Management

Under the new Medicare ASC payment system, payments for some covered surgical codes are discounted or packaged. Here's a look at what this means for ENT reimbursement.

  • Discounting. Multiple procedure discounting is applied when more than one surgical procedure is performed during a single operative session. The full Medicare payment is made, and the beneficiary pays the full coinsurance amount for the procedure having the highest payment rate. Fifty percent of the Medicare payment amount and the beneficiary coinsurance amount is paid for all other procedures performed during the same operative session, to reflect the savings associated with having to prepare the patient only once and the incremental costs associated with anesthesia, OR and recovery room use, and other services required for the second and subsequent procedures. Notably, ENT procedure code 30300 (removal foreign body, intranasal; office type procedure) is not subject to multiple procedure discounting. This procedure is always paid at 100 percent — even if other procedures are performed during the same session.
  • Packaging. Packaged services are those that are recognized as contributing to the cost of the services under the new ASC payment system, but that CMS doesn't pay for separately. Many ENT physicians perform sinus surgery using stereotactic computer-assisted volumetric navigation (code 61795) or three-dimensional rendering with CT scan imaging (codes 76376/76377). Under the new payment system, these services are packaged and don't generate separate payments from Medicare.

Covered Procedures Aren't Always Covered

The inclusion of a procedure in the new ASC payment system doesn't guarantee that your local Medicare carrier will cover the procedure. Case in point: Although all of the rhinoplasty CPT codes 30400 to 30450 are covered under the new ASC payment system, some Medicare carriers will only reimburse when the rhinoplasties are performed for certain medical conditions. This is because procedures CMS has identified as "covered" under the new ASC payment system are still subject to any applicable local coverage determination. An LCD, as it is known, is a decision by a Medicare carrier or fiscal intermediary as to whether the service is reasonable and necessary. These LCDs are constantly changing, even more so when new CPT codes are released. For a state-by-state listing of LCDs go to: www.cms.hhs.gov/mcd/index_lmrp_bystate.asp. As a practical matter, implement a process or continue existing processes for validating — at the time of surgery scheduling — the coverage of surgical procedures for Medicare patients.

— Lolita M. Jones, RHIA, CCS

Although CMS hasn't addressed ASC reporting of packaged services, in the Nov. 27, 2007, Federal Register (page 66611), CMS stated: "To the extent possible, hospitals may use HCPCS codes to report any packaged services that were performed, consistent with CPT or CMS coding guidelines."

Although separate payments won't be generated, ASCs should strongly consider coding, charging and billing packaged services on the claims submitted to Medicare, just as CMS has advised hospitals.

  • Transitional payments. To provide additional time for ASCs to adapt to the new payment system and to facilitate Medicare beneficiary access to ambulatory surgical procedures at those ASCs that may not adjust as quickly as others to the new payment system, CMS has adopted a transition period of four years. The contribution of calendar year (CY) 2007 ASC payment rates to the blended transitional rates will decrease by 25 percentage point increments each year of transitional payment until CY 2011, when CMS will fully implement the ASC payment rates calculated under the final methodology of the new payment system.

Most of the ENT procedures listed in "Commonly Performed ENT Procedures" have a 2008 payment that is higher than the 2007 rate under the former payment system. A few codes, however, now have lower payments, such as release of nasal adhesions (code 30560) and control of nosebleeds (codes 30903 to 30906). Procedures new to ASC payment for CY 2008 or later calendar years aren't subject to the transition policy. New procedures receive payments determined according to the final methodology of the new ASC payment system. For example, removal of nasal foreign body (code 30300) was not covered in 2007, and it is now recognized under APC group 340.

Commonly Performed ENT Procedures

CPT Code

Description

Multiple Procedure Discounting?

2007 Payment

2008 First Transition Year Payment

APC Group*

30130

Excise inferior turbinate

Y

$510.00

$551.51

0253

30140

Resect inferior turbinate

Y

$446.00

$582.66

0254

30150

Partial removal of nose

Y

$510.00

$795.24

0256

30160

Removal of nose

Y

$630.00

$885.24

0256

30200

Injection treatment of nose

Y

$62.00

0252

30210

Nasal sinus therapy

Y ?

$78.36

0252

30220

Insert nasal septal button

Y

$464.15

$425.20

0252

30300

Remove nasal foreign body

N

?

$26.12

0340

30310

Remove nasal foreign body

Y

$333.00

$418.76

0253

30320

Remove nasal foreign body

Y

$446.00

$503.51

0253

30400

Reconstruction of nose

Y

$630.00

$885.24

0256

30410

Reconstruction of nose

Y

$717.00

$950.49

0256

30420

Reconstruction of nose

Y

$717.00

$950.49

0256

30430

Revision of nose

Y

$510.00

$630.66

0254

30435

Revision of nose

Y

$717.00

$950.49

0256

30450

Revision of nose

Y

$995.00

$1,158.99

0256

30460

Revision of nose

Y

$995.00

$1,158.99

0256

30462

Revision of nose

Y

$1,339.00

$1,416.99

0256

30465

Repair nasal stenosis

Y

$1,339.00

$1,416.99

0256

30520

Repair of nasal septum

Y

$630.00

$720.66

0254

30540

Repair nasal defect

Y

$717.00

$950.49

0256

30545

Repair nasal defect

Y

$717.00

$950.49

0256

30560

Release of nasal adhesions

Y

$150.72

$138.92

0251

30580

Repair upper jaw fistula

Y

$630.00

$885.24

0256

30600

Repair mouth/nose fistula

Y

$630.00

$885.24

0256

30620

Intranasal reconstruction

Y

$995.00

$1,158.99

0256

30630

Repair nasal septum defect

Y

$995.00

$994.41

0254

30801

Ablate inf turbinate, superf

Y

$333.00

$326.83

0252

30802

Cauterization, inner nose

Y

$333.00

$326.83

0252

30901

Control of nosebleed

Y

?

$44.63

0250

30903

Control of nosebleed

Y

$72.48

$66.01

0250

30905

Control of nosebleed

Y

$72.48

$66.01

0250

30906

Repeat control of nosebleed

Y

$72.48

$66.01

0250

30915

Ligation, nasal sinus artery

Y

$446.00

$601.96

0092

30920

Ligation, upper jaw artery

Y

$510.00

$649.96

0092

30930

Ther fx, nasal inf turbinate

Y

$630.00

$641.51

0253

31231

Nasal endoscopy, dx

Y

$66.72

0072

31233

Nasal/sinus endoscopy, dx

Y

$86.39

$81.47

0072

31235

Nasal/sinus endoscopy, dx

Y

$333.00

$425.87

0074

31237

Nasal/sinus endoscopy, surg

Y

$446.00

$510.62

0074

31238

Nasal/sinus endoscopy, surg

Y

$333.00

$425.87

0074

31239

Nasal/sinus endoscopy, surg

Y

$630.00

$707.65

0075

31240

Nasal/sinus endoscopy, surg

Y

$446.00

$510.62

0074

31254

Revision of ethmoid sinus

Y

$510.00

$617.65

0075

31255

Removal of ethmoid sinus

Y

$717.00

$772.90

0075

31256

Exploration maxillary sinus

Y

$510.00

$617.65

0075

31267

Endoscopy, maxillary sinus

Y

$510.00

$617.65

0075

31276

Sinus endoscopy, surgical

Y

$510.00

$617.65

0075

31287

Nasal/sinus endoscopy, surg

Y

$510.00

$617.65

0075

31288

Nasal/sinus endoscopy, surg

Y

$510.00

$617.65

0075

61795

Brain surgery using computer

N

Packaged

Packaged

76376

3d render w/o postprocess

N

Packaged

Packaged

76377

3d rendering w/postprocess

N

Packaged

Packaged

* Services within the APC system are identified by HCPCS Level I (CPT) and Level II (national) codes and descriptions. The compositions of the APC groups rest on two premises: The procedures within each group must be similar both clinically and in terms of resource costs.

ENT coding tips
Accurate and comprehensive coding is a major factor in ASCs receiving optimal payments under the APC system. Here are some ENT surgery coding guidelines applicable to all healthcare providers.

  • It's OK to report CPT codes 31238 (endoscopic control of epistaxis) and 31237 (endoscopic polypectomy) appended with modifier -59 when the epistaxis is unrelated to the polypectomy. However, if subsequent bleeding is caused by the performance of a polypectomy or biopsy and control of bleeding is performed at this time, don't separately report code 31238 for the control of epistaxis in this instance. (Source: CPT 2000 Coding Symposium handout, American Medical Association, Chicago, Ill.)

  • When reporting turbinate submucous resection code 30140, documentation in the operative report should reflect that the physician entered or incised the mucosa and, for the most part, preserved it. The simple statement, "excised the turbinate(s)" is often not enough documentation to reflect that the submucous resection of the inferior turbinate was performed. Coders may need to ask the physician for the specific technique performed. (Sources: May 2003 and December 2004 CPT Assistant newsletters, AMA.)
  • Don't report turbinate fracture code 30930 with submucous resection code 30140 if the procedures are performed on the same turbinate. (Source: December 2004 CPT Assistant newsletter, AMA.)
  • Turbinate injection code 30200 is a bilateral procedure, so bilateral procedure modifier -50 is not needed for this code. (Source: December 2004 CPT Assistant newsletter, AMA.)
  • The reference to "tissue" in endoscopic maxillary antrostomy code 31267 can include polyps, mucous membrane, bony partitions or massive fungal concretions/debris. (Source: CPT Assistant newsletter, January 1997, page 6.)
  • Report code 31237 (without a modifier) each time you perform a post-op endoscopic debridement (without a biopsy or polypectomy) following functional endoscopic sinus surgery (FESS). (Source: December 2001 CPT Assistant newsletter, AMA.)
  • Report code 61795 (stereotactic computer assistance) when performed in conjunction with ENT, head and neck procedures, including FESS. Examples would include those procedures described by codes 31254 to 31256, 31267, 31276, 31287, 31288, 31290 to 31294, and 61548. (Source: October 2001 CPT Assistant newsletter, AMA.)

ICD-9-CM Codes That Support Medical Necessity for Rhinoplasty (CPT 30400 to 30450)

160.0

Malignant neoplasm of nasal cavities

170.0

Malignant neoplasm of bones of skull and face except mandible

172.3

Malignant melanoma of skin of other and unspecified parts of face

173.3

Other malignant neoplasm of skin of other and unspecified parts of face

195.0

Malignant neoplasm of head face and neck

212.0

Benign neoplasm of nasal cavities middle ear and accessory sinuses

213.0

Benign neoplasm of bones of skull and face

216.3

Benign neoplasm of skin of other and unspecified parts of face

232.3

Carcinoma in situ of skin of other and unspecified parts of face

802.0

Closed fracture of nasal bones

802.1

Open fracture of nasal bones

SOURCE: Wisconsin Medicare Carrier Local Coverage Determination (#L17996) for Rhinoplasties

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