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By: Lolita Jones
Published: 5/14/2008
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.
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.
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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.
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.
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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