January 2003: Patient Advocacy Update

Joseph Jacobs, MD
New York, NY

Socioeconomic issues continue to require vast expenditures of both time and money by organized medicine. The American Rhinologic Society clearly recognizes the adverse impact upon our member's ability to practice quality medicine. We are therefore expanding our direct efforts to provide up to date verifiable material for the membership regarding the submission of "clean" claims as well as various avenues to engage in active protest of claim and CPT code denials. The following information highlights these efforts.

The ARS web site, www.american-rhinologic.org, provides data and documentation which should be utilized in contesting denials of various CPT codes including 31237 and 61795. We are presently updating and reorganizing the site to include sample letters of protest that our membership can access, copy to their own stationary and utilize to vigorously protest third party payor denials. This material has been drafted through the combined efforts of the Patient Advocate Committee [formerly the Socioeconomic Committee] and our legal team in Washington, D. C., Hogan and Hartson. In addition, the original documents from the ARS, AMA and CMS (formerly HCFA) detailing the approval of reimbursement for 61795 when utilized with sinus surgery are available to be downloaded. This material should be included when contesting the denial of this code. In addition, we are adding a section concerning the complicated subject of turbinate and septal surgery when performed with FESS. As many of you are aware, carriers often deny reimbursement for these codes suggesting that they are either inclusive or should be bundled with FESS. Much of this confusion relates to CCI edits. We will highlight this topic and provide documentation that can be utilized to challenge these third party payor denials.

The ARS newsletter, Nose News, provides important information relating to practice expense updates as well as socioeconomics. Please carefully review this section and contact either the editor, Brent Senior, or the Patient Advocate Committee chair, Mike Sillers, with any questions. The AAOHNS is adopting a position statement for 61795 and has available similar documents concerning other CPT codes relevant to our society. The Academy publishes a Clinical Indicators Compendium which lists clinical indicators for various CPT codes as well the linked ICD-9 diagnostic codes. Claim submission without such an approved diagnostic code will generally result in immediate computer denial.

I recently discussed the issue of modifiers 51, 59 and 79 with our attorneys. Modifier 51 can be added to various rhinologic CPT codes to clarify that "more than one stand alone procedure was performed during the same operative session." As an example, if 31256 is being denied when performed with 31255, consider adding this modifier to one or more of the lesser valued codes. In addition, please remember to continue to include the 50 bilateral modifier if appropriate. Modifier 59 indicates that a procedure or service performed on the same day should not be bundled into other codes. Examples where 59 might provide benefit include turbinate codes and septal codes and 61795. Lastly, modifier 79, an unrelated procedure during the "global period" can be routinely appended to 31237 and more importantly when septal and turbinate surgery have been performed with FESS since the former DO NOT have zero global periods. Please carefully utilize the appropriate ICD-9 codes for each CPT code and be specific within your operative report to substantiate the indication for each procedure.

In addition, CPT code 31231 is either unilateral or bilateral, however the remaining FESS codes including 31237 can be coded as bilateral with a 50 modifier. Remember to be specific with the linked ICD-9 codes and document the procedure with endoscopic findings and suggested therapy whether performed in the office or operating room.

Mike Sillers is the incoming chair of the Patient Advocate Committee. I will continue to provide support during the coming academic year. I strongly urge ARS members to contact us directly for information and guidance.


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Revised 1/2003
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