Successfully Appeal Inappropriate Septoplasty Denials to Gain Reimbursement
- Published on Sat, Apr 01, 2000
Many insurance carriers still inappropriately bundle endoscopic sinus procedures with septoplasties. Consequently, otolaryngologists must be prepared to appeal these denials to gain proper reimbursement for their services.
The carriers claim the septoplasty is incidental because it is performed to improve the otolaryngologists access to the sinuses. This view that was bolstered in January 1999 when GMIS ClaimCheck, a commercial software editing package produced by McKesson-HBOC, bundled the two procedures. The edit prompted a storm of protest by otolaryngologists and was removed in November.
Not all carriers have removed the bundle from their software, however, so the procedures still are being denied, and coders need to carefully monitor reimbursement when these two procedures are performed.
Septoplasty Performed for Distinct Medical Reasons
Septoplasties are performed during the same operative session as endoscopic sinus surgery when a patient with sinusitis also has a deviated septum. For example, an otolaryngologist evaluates a patient with chronic sinusitis in the maxillary sinus (473.0) and determines the patient has a deviated septum (470). The otolaryngologist schedules the patient for endoscopic sinus surgery (31267, nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus) and a septoplasty (30520, septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft) to correct the deviated septum, which is creating a nasal obstruction and also may be a contributing factor for the sinusitis.
In this situation, the otolaryngologist likely performs the septoplasty first, because this also will improve access to the maxillary sinus. Some carriers have denied claims on this basis, maintaining that because the septoplasty was performed first and improved access, it is incidental and shouldnt be paid.
This, however, is not the case, according to the American Academy of Otolaryngologists-Head and Neck Surgery (AAO-HNS). When a septal operation is performed at the same time [as endoscopic sinus surgery], it is performed because of unrelated pathology. Most commonly, the septal deformity is blocking the nasal airway and obstructing the patients breathing. This is independent of the sinus pathology and performing the sinus operation alone would be insufficient to correct the pathology. Far less frequently, the septal deformity is impinging onto the turbinates, acting as an etiology contributing to the development of sinus pathology. In such cases, while the sinus pathology itself requires correction, the anatomic deformity of the septum also warrants separate correction so that further sinus pathology does not recur.
In other words, the septoplasty and endoscopic sinus surgery are being performed for distinct medical reasons. But otolaryngologists sometimes inadvertently give carriers ammunition for denying the septoplasty because of the way they write their operative notes, says Barbara Cobuzzi, CPC, CPC-H, CHBME, an independent [...]
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