CPT for ENT: Turbinectomy Guidance

CPT for ENT: Turbinectomy Guidance

 

Q:  I am experiencing denials on turbinectomy codes 30130 and 30140 when billed concurrently with a septoplasty or endoscopic sinus surgery procedures. Can you explain why?

A: The Academy has received many inquiries related to the claims processing of CPT code 30130, Excision inferior turbinate, partial or complete, any method and CPT code 30140, Submucous resection inferior turbinate, partial or complete when rendered concurrently with either septoplasty or endoscopic sinus procedures. This has reportedly been attributed, by carriers, to misapplication of these codes by members of our specialty.

Whether you are a physician, advanced medical coder, or a student in training there are a few critical facts from the May 2003 issue of CPT Assistant that you should review starting with the anatomy:

Turbinates are bony plates covered by spongy mucosa also known as Conchae.

  1. There are three turbinates on each side of the nasal vestibule: inferior, middle, and superior.
  2. Generally, the inferior turbinate is covered with relatively thick mucosa and is located on the lower lateral wall of the nasal cavity. It articulates with the ethmoid, lacrimal bone, maxilla and palate. This turbinate is very important in determining nasal airway patency.
  3. The middle turbinate is a part of the ethmoidal labyrinth (bone), projecting from the lateral wall of the nasal cavity
  4. The superior turbinate is the smallest turbinate and uncommonly associated with significant nasal/sinus disease. The superior turbinate is also part of the ethmoidal labyrinth, projecting from the upper lateral wall of the nasal cavity near the sphenoethmoidal recess. Next, let’s review the diagnostic problems causing sinus conditions; there are several key points to consider when coding turbinate procedures. As such, it is important to identify the type of turbinate procedure and the appropriate technique that is performed.
    • Chronic nasal obstruction due to inferior turbinate hypertrophy from multiple causes (allergy, rhinitis medicamentosa, vasomotor rhinitis, etc.)
    • Chronic infection, or allergy with continuous or intermittent nasal symptoms
    • Turbinates that are obstructive and not responding to aggressive medical management may require surgical treatment.
    • Turbinates may be reduced in size or removed by any one (or combination) of several modalities: resection / excision (with /without endoscopes), cauterizations, sub mucosal debridement, laser, trimming, cryotherapy, radiofrequency reduction or ablation

Changes in CPT Reporting:

Prior to January 2006, CPT did not specifically differentiate the turbinates. At present, CPT codes 30130 and 30140 now refer specifically to the inferior turbinates (as do codes 30801, 30802, and 30930). Clinically, as the AAO-HNS continues to stress, the inferior turbinates are not associated with sinus surgery or are they inherently part of, or necessary to address when performing, septal surgery. Turbinate surgery, while carried out transnasally, involves separate anatomical sites, application of separate clinical judgment, surgical technique and instrumentation and thus should be reported and reimbursed separately from sinus and septal operations. However, in a strict anatomic sense, the middle turbinate is part of the ethmoid bone. Therefore, if the middle turbinate is removed when performing endoscopic ethmoidectomy (codes 31254, 31255) or endoscopic polypectomy (code 31237), the removal of the middle turbinate (code 30999) would not be reported separately. You may report the inferior or superior turbinate procedures separately when the documentation accurately reflects the correct anatomical site. It has long been the position of the Academy that middle turbinectomy procedures CPT code 30999 are separate from procedures on the sphenoid, maxillary, or frontal sinus or the nasal septum. Resection of a concha bullosa 31240 is reported separately from all sinus and septal surgery.

Documentation and Medical Necessity

When documenting for CPT code 30140, Submucous resection of the inferior turbinate, partial or complete, any method, the medical record should reflect that the physician entered or incised the mucosa, with its preservation, while removing or reducing a portion of the underlying bone and/or soft tissue. A simple statement such as "excised the turbinate(s)" is not enough documentation to reflect that submucous resection was performed nor would it reflect the documentation required if the procedure had been performed bilaterally. 30130 Excision inferior turbinate, partial or complete, any method should be used if a portion of the inferior turbinate is removed.

Always document the reason or diagnosis for performing the turbinate procedure, such as hypertrophy (ICD-9 CM code 478.0) or nasal airway obstruction (478.1). If a surgical procedure was performed simply to gain access to another anatomic area, payors will generally not reimburse. The following CPT codes are considered unilateral: 30130 and 30140. It is also important to note that the Medicare global period is 90 days whereas the global period for most endoscopic sinus surgery codes is 0 days (that is, the only services associated with the codes are those provided on the day of the procedure). Therefore, if you have operated on the inferior turbinates or septum you should add the modifier -79, Unrelated Procedure or Service by the Same Physician During the Postoperative Period to code 31237 (sinus debridement) to override the 90 day global periods for 30130 or 30140. Note: Payers that use a multiple of RBRVS values to reimburse should utilize the same global periods as Medicare, as this is integral to each codes valuation.

We advise all members of the Academy and their staff to pay close attention to the claims adjudication of turbinate and sinus/septal surgery. If your documentation clearly reflects the separate diagnosis required to identify the medical necessity, append the modifier -59 Distinct Procedural Service to the CPT code being reported. This modifier is attached to the code you want to tell the payer is a separate procedure, i.e., the one that might be included in, or bundled with, another service. Some carriers may want documentation with the initial claim submission, but many will request clinical notes only upon appeal.

The Academy is here for you. Please do not wait until you have exhausted all appeals before calling us especially if you have noticed a pattern of non-payment by a payer. Provide the best medical care possible for your patients, document with the same level of rigor, and, if you have questions, make the Academy your first stop in the appeals process.

Richard Waguespack, MD
Coordinator for Socioeconomic Affairs
Physician Payment Policy (3P) Co-Chair

Charles F. Koopmann, JR., MD
CPT & Relative Value Committee member
CPT Assistant Editorial Board member
Physician Payment Policy (3P) Workgroup member

Revised June 13, 2012
Revised October 2009
Reviewed April 2008
Approved June 2012

Important Disclaimer Notice (Updated 8/7/14)

CPT for ENT articles are a collaborative effort between the Academy’s team of CPT Advisors, members of the Physician Payment Policy (3P) workgroup, and health policy staff. Articles are developed to address common coding questions received by the health policy team, as well as to clarify coding changes and correct coding principles for frequently reported ENT procedures. These articles are not intended as legal, medical, or business advice and are not a guarantee of reimbursement. The information is also not meant to serve as the definitive or sole authority on billing and coding issues. The applicability of AAO-HNS billing and coding guidance for a particular procedure, must be determined by the responsible physician in light of all the circumstances presented by the individual patient. You should consult with your own advisors as well as Medicare or private carriers in making any decisions about how to bill and code particular services or procedures.