Учебники / Pediatric Sinusitis and Sinus Surgery Younis 2006

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4.American Academy of Otolaryngology Head–Neck Surgery practice management resources, including www.ENTcodingtoday. com

5.E-subscriptions to payor websites including Medicare

6.International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)for diagnosis coding (updated annually)

Many of these resources are available through electronic means. In fact, Medicare no longer publishes paper monthly manuals.

To ensure accurate reporting of services, use the appropriate charge capture tools. The goal is timely capture of charges for office services, any ancillary-owned services, and surgery center or hospital services including any emergency room consultations, in-hospital consultations, and subsequent hospital visit services.

The AMA CPT manual contains all the CPT codes for reporting office and surgical services. The manual is broken down into sections: evaluation and management, anesthesia, surgical, medicine, radiology, pathology/ laboratory, and category-III codes.

The key sections of the CPT manual for a sinus practice/sinus center specifically include the evaluation and management section, the surgical section for reporting surgical sinus procedures, the medicine section for allergy-related services, pathology/laboratory for any RAST testing or other related services, and radiology for sinus X-rays, CT scans, and other radiology services.

CODING OFFICE-BASED PROCEDURES

If the physician sees a new patient in the office and performs a diagnostic nasal endoscopy, the physician may report both the new patient’s visit and the endoscopy if the documentation supports both services.

According to the AMA CPT rules, the physician may report both the new patient’s visit and the endoscopy if the evaluation and management (E&M) service is a significant separate service. Table 2 shows how the physician reports this service according to the 2005 AMA CPT rules.

The CPT rules state it is not necessary to have two separate diagnoses to report the E&M service and the endoscopy. The E&M service is considered as

Table 2	Office Coding
CPT code/
modifier	Description	ICD-9-CM
9920x–25	Office or other outpatient service	473.0 (chronic maxillary
	for a new patient	sinusitis)
31231	Nasal endoscopy, diagnostic, unilateral, or	473.0 (chronic maxillary
	bilateral (separate procedure)	sinusitis)

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a significant, separate service, because this is a new patient the physician never examined in the past. Assuming the documentation requirements are met, the physician reports both services and appends modifer-25.

Modifier-25 indicates to the payor that the E&M is a significant separate service on the same day as a minor procedure. This modifier tells the payor it was necessary to do the E&M, and reimbursement is expected on both services.

CODING SURGICAL SINUS PROCEDURES

To accurately report sinus surgical procedures, the physician will choose a code based on:

Surgical approach, i.e., open versus endoscopic

Unilateral or bilateral procedures

Sinus procedures with or without removal of tissue

Additionally, the physician will indicate if additional procedures were performed at the same operative session, such as:

Turbinate surgery (document location of turbinates)

Septal surgery

Each service performed and reported to the payor must include a diagnosis code to support the medical necessity of the service.

For example, according to the 2005 AMA CPT rules, the physician reports the following procedure accordingly in Table 3.

Pre-Op Diagnosis:

Chronic ethmoid sinusitis

Chronic maxillary sinusitis

Post-Op Diagnosis:

Chronic ethmoid sinusitis

Chronic maxillary sinusitis

Sinus polpys

Procedure:

Bilateral endoscopic total ethmoidectomy

Bilateral endoscopic maxillary antrostomy with removal of sinus polyps.

Key coding and documentation and reimbursement considerations in the above example include:

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Reporting services using the CPT appropriate code (i.e., specific sinus with or without tissue removal)

Documentation of procedure as endoscopic (approach)

Dictation of procedure as bilateral

Identification of specific sinuses and inclusion of tissue removal in the maxillary sinus

List CPT codes in descending value order

Appropriate use of modifier-50 (bilateral procedures on second CPT codes 31255 and 31267)

Appropriate use of modifier-51 (multiple procedure) on CPT code 31267 (first time it is listed)

Link procedures to specific diagnosis code avoiding the use of a ‘‘pansinusitis’’ diagnosis

Document removal of polyps in procedure dictation (operative note detail will also include the removal of polyps in the maxillary sinus)

Key reimbursement consideration for this case as submitted (Table 4):

1.List procedures in descending value order and ensure the Explanation of Benefts (EOB) form is returned with the same CPT codes and modifiers.

2.Post the surgical cases by line item into the computer system. (See table that follows to show line item posting.)

3.Obtain the payor’s fee schedule and put the fee schedules into the computer system. This will allow you to detect any payments not made at the expected rate.

4.Watch EOBs closely to ensure proper payment is received. Independent of how the codes are submitted (line item vs. linear), expect payment to be made according to the multiple procedure payment formula. Currently, Medicare reimburses:

100% for the first procedure

50% for the second procedure

50% for the third procedure

50% for the fourth procedure

50% for the fifth procedure

after the fifth procedure, reimbursement is at payor discretion

Post all payments and non-payments received. For any non-payments, post zero dollars and leave the line item open. Post the denial reason, and then begin the appeal/account-follow-up process.

For any non-payments, ensure the case was coded correctly, modifiers placed appropriately, and the diagnosis supports the medical

Table 3 Surgical Sinus Coding and Line Item Reporting

CPT code/			2005 RVUs	Expected reimburse-
modifier	Description	ICD-9-CM	(Medicare)	ment RVUs
31255	Nasal/sinus endoscopy, surgical; with ethmoidectomy, total	473.2	11.79	11.79
	(anterior and posterior)
31255-50	Nasal/sinus endoscopy, surgical; with ethmoidectomy, total	473.2	11.79	5.90
	(anterior and posterior)
31267-51	Nasal/sinus endoscopy, surgical, with maxillary antrostomy;	473.0	9.29	4.65
	with removal of tissue from maxillary sinus
31267-50	Nasal/sinus endoscopy, surgical, with maxillary antrostomy;	473.0	9.29	4.65
	with removal of tissue from maxillary sinus

Note: This example uses RVUs to demonstrate fees. The physician practice and surgical center will report actual fees.

Table 4 Surgical Sinus Coding and Linear Posting (Medicare Preferred Method)

CPT code/			2005 RVUs
modifier	Description	ICD-9-CM	(Medicare)	Expected reimbursement RVUs
31255-50	Nasal/sinus endoscopy, surgical; with	473.2	11.79 or 23.58	17.69 (150%) total both procedures
	ethmoidectomy, total (anterior and
	posterior)
31267-50	Nasal/sinus endoscopy, surgical, with	473.0	9.29 or 18.58	9.29 (100%) total for both procedures
	maxillary antrostomy; with removal of			(the second set of code assumes payor
	tissue from maxillary sinus			reimburses 100%–50%–50%–50%).

Note: This illustration uses RVUs to demonstrate fees. The physician practice and surgical center will report actual fees.

Determine if payor wants fee submitted at one time normal fee or double fee for both procedures. Medicare will apply a double adjudication to second 31267-50 and pay at 75%.

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necessity of the service. If the answer to any of these three factors is no, correct the claim prior to appealing.

Sample: Linear Posting

NOTE: When payors instruct you to submit your services linear, ask them the following questions:

1.How many units go in the unit box, i.e., one or two?

2.Do I submit my fee one time, or do I double my fee?

These questions can only be answered by the payor.

CHARGE ENTRY AND ACCOUNT FOLLOW-UP

Time of Service (TOS) Charge Entry and Payment Posting

Ideally, charge entry for physician offices occurs at the end of the patient visit at checkout. Timely posting of charges is essential as payors are decreasing their filing deadlines and appeal deadlines.

Post all charges at the time of service, as well as collecting and posting of any payments due from the patients. The TOS payments include, but are not limited to, co-pays, deductibles, self-pay responsibilities, and outstanding patient balances.

At the end of each day, a ‘‘daily close’’ is performed to ensure charges are captured for all patients seen that day.

Charge posting for surgical cases should occur within 24 to 48 hours of the surgical case. In today’s market, practices have to provide CPT codes and diagnosis codes when precertifying a case. If the physician provides the CPT codes to precertify the case, coding the case after surgery requires the physician to review the precertified codes and modify any surgical CPT codes provided on the front end to the actual surgical procedure performed.

Any delay in charge entry places the practice or center at risk for delayed reimbursement or denied reimbursement if filing deadline dates are passed.

CLAIM SUBMISSION

All claims that can be sent electronically should be sent immediately after the posting session. Verify that payors have received the claims and that the information provided is ‘‘clean.’’

Posting Payments, Appeals, and Account Follow-Up

Ideally, all charges and payments are entered into the computer system in line item format, which allows the staff to post all payments or non-payments directly against the service posted.

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If a payor’s EOB form identifies the reason for a rejection or denial, post this into the system so that you may trend payor activity regarding reasons for non-payment.

WATCHING REIMBURSEMENT

As demonstrated in the previous clinical examples (Tables 1–3), monitoring coding and documentation is critical to ensuring accurate reimbursement.

In the office examples, payors will frequently ‘‘bundle’’ the E&M service into the surgical procedure as part of the surgical package and only reimburse the surgical procedure.

Astute billing office staff will detect this when posting the services and begin the appeal process. Action steps for the appeal will include:

1.review the reason for denial to begin the appeal process

2.check the diagnosis code to ensure the diagnosis supports the medical necessity of both services

3.review the E&M for documentation requirements

4.ensure the nasal endoscopy procedure and findings are documented

5.make sure modifier-25 was appended to the E&M when the claim was submitted

6.review the reason for denial

Table 5	Sinus Surgery Procedure Codes and RVUs
			Expected
CPT code/		2005 RVUs	reimbursement
modifier	Description	(Medicare)	RVUs (2005)
31255	Nasal/sinus endoscopy,	11.79	11.79	(100%)
	surgical; with ethmoidectomy,
	total (anterior and posterior)
31255-50	Nasal/sinus endoscopy,	11.79	5.73	(50%)
	surgical; with ethmoidectomy,
	total (anterior and posterior)
31267-51	Nasal/sinus endoscopy,	9.29	4.50	(50%)
	surgical, with maxillary
	antrostomy; with removal of
	tissue from maxillary sinus
31267-50	Nasal/sinus endoscopy,	9.29	4.50	(50%)
	surgical, with maxillary		(see note)
	antrostomy; with removal of
	tissue from maxillary sinus

Note: This illustration uses RVUs to demonstrate fees. The physician practice and surgical center will report actual fees. Medicare will apply a double adjudication to a CPT code 31267-50 and pay at 25% for second bilateral procedure.

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If the claim is clean and documentation supports the services, the staff contacts the payor via telephone as the first line of appeal. The goal is to overturn the denial via the telephone versus a written appeal. If this is not successful, the staff writes a formal appeal letter.

The major concern with the surgical example is ensuring the payors reimburse appropriately on the multiple sinus procedures. Currently, many payors reimburse according to Medicare’s multiple procedure payment formula, but may develop their own payment formula. Assuming Medicare’s 100%, 50%, 50%, 50%, and 50% formula previously outlined, we expect to see the surgical procedures reimbursed as follows in Table 5, unless they apply for double adjudication on the 4th procedure.

INFORMED CONSENT/MEDICOLEGAL ISSUES

In order to maintain a high standard of practice, one should familiarize oneself with the American Academy of Otolaryngology-Head and Neck Surgery guidelines for management of sinus and nasal disease. The otolaryngologist and/or other surgeons involved in the facility, as well as the nursing staff and anesthesia staff, must be appropriately licensed to perform the various procedures incorporated into the surgical facility. Optimal medical documentation of procedures must be developed, including those addressing medical necessity and comprehensive informed consent. In particular, informed consent must be obtained preoperatively and must be incorporated into the record. Sinonasal surgery represents a high risk for potential medicolegal action. Informed consent can be obtained by various methods although a comprehensive discussion with the patient together with signing a document affirming this usually serves the physician well. Figure 1 is an example of a comprehensive review of the risks associated with sinonasal surgery. This consent form, modified to suit your practice, will provide excellent documentation for an informed consent discussion (Fig. 1).

By signing this document, the patient agrees that informed consent has been obtained and that the patient fully understands the risks, benefits, and reasonable alternatives to the proposed surgical procedure. Also, postoperative documentation, including the operative procedure, should be dictated immediately following the surgery, and should be complete and accurate.

In addition, from a medicolegal perspective, the operating suite should be safe, well-equipped, and fully functional to deal with all possible emergencies including resuscitation, if needed. Training and certification for staff need to be current.

Business property and liability insurance are mandatory and coverage should include loss or damage to business-owned property, equipment, infrastructure, and other associated potential losses. In addition, medical malpractice and professional liability insurance is required prior to initiating any services in the sinus center. For the most part, one million dollars per

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Figure 1 Informed consent for endoscopic sinus surgery, septoplasty, and other nasal surgeries.

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Figure 2 Credentialing organizations.

occurrence and three million dollars aggregate coverage is an average used by most physicians. The otolaryngologist and all levels of support personnel should obtain malpractice coverage in addition to coverage offered by the physician’s malpractice policy.

CREDENTIALING

Office-based and freestanding surgical facilities require credentialing by one or more organizations. Usually a Certificate of Need (CON) application is required for more than one operating room in an outpatient facility; however, these regulations are becoming less stringent in many states, especially as patient access improves and the safety and viability of alternative surgical facilities continue to grow. Credentialing occurs at both the federal and state level and varies from state to state. In order to operate, most surgery centers require credentialing from the Center for Medicare and Medicaid Services (CMS). This ensures payment from the Health Care Finance Administration (HCFA). With Medicaid credentialing in place, most state and local third party insurers will follow suit, although this is not universal.

Two voluntary accrediting organizations, namely the Joint Commission on the Accreditation of Health Care Organizations (JCAHO) and the Accreditation Association for Ambulatory Health Care (AAAHC), have also been approved to accredit Medicare facilities. In general, accreditation is a lengthy, detailed process that requires extensive planning and prepa-

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ration and may require 6 to 12 months or longer to complete. Each of the credentialing organizations has specific criteria and requirements that are clearly documented and which need to be adhered to completely to facilitate accreditation. Both the facility and any physician using the facility must be credentialed and a detailed policy and procedures manual needs to be maintained reflecting, among other things, credentialing by the facility, physician, and supporting staff. Contact information for AAAHC and JCAHO is provided (Fig. 2).

OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION

The Occupational Safety and Health Administration (OSHA) is a division of the Department of Labor which has a critical oversight role in reference to the ‘‘blood–borne pathogen standards’’ to insure workers’ safety with minimization of exposure to HIV, hepatitis, and other blood–borne pathogens transmitted in job-related tasks. Each facility has to have a well-docu- mented workable exposure control plan (ECP) and the plan must be comprehensive and readily available to employees. OSHA has strict requirements with respect to annual updates, and periodic site visits may be performed. Detailed protocols are available from OSHA regarding the various categories for employees with different likelihood of exposure. Documentation of training is an important part of OSHA requirements.

Hazards in the workplace including scalpels and needles need to be appropriately disposed of in SHARPS containers, scalpel and needle dispensers, and soiled linen receptacles. Noxious or toxic chemicals also need to be appropriately removed.

Personal protective clothing and equipment (PPCE) must be readily available to employees. One must provide gloves, gowns, and laboratory coats as well as face shields and other eye protection as well as caps and masks especially when a recognized risk level for contamination is present. One has to cater to the specific requirements of the employee, for example, hypoallergenic and latex free gloves.

Engineering and work practice controls are also mandated by OSHA to limit employee exposure to blood–borne pathogens.

Universal precautions should be practiced as a matter of routine. Hepatitis B vaccines should be provided to all office staff, especially in the clinical realm where exposure might be anticipated. Appropriate documentation of OSHA issues must be maintained.

The OSHA requirements are quite extensive and additional material is available directly from OSHA as well as the AMA. The OSHA web site address is http://www.osha.gov.