2014 physician billing guide for nasal/sinus endoscopic

2014 PHYSICIAN BILLING GUIDE FOR NASAL/SINUS ENDOSCOPIC SURGERY Some of the Current Procedure Terminology (CPT®) Codes for endoscopic nasal/sinus surgery are listed below. CPT codes 31295, 31296 and 31297 apply to cases in which a balloon catheter is the only instrument/tool used to create the opening and no tissue is removed. When balloons are used in combination with other instruments/tools and tissue is removed, the existing endoscopic sinus surgery codes are the appropriate codes to report per the guidance of CPT Assistant (January 2010/Volume 20, Issue 1) and AAO‐
HNSF’s coding guidance, found at: http://www.entnet.org/Practice/Coding‐for‐Balloon‐Sinus‐Dilation‐2010.cfm . Endoscopic sinus surgery codes are unilateral, therefore modifier ‐50 should be used when billing for bilateral procedures. CPT 30140 30420 30520 30801 31000 31002 31231 31237 31240 31254 31255 31256 31267 31276 31287 31288 31295 31296 31297 Global
Description Submucous resection, inferior turbinate, partial or 090 complete, any method Rhinoplasty, primary; including major septal repair
090
Septoplasty or submucous resection, with or without 090 cartilage scoring, contouring or replacement with graft
Cautery and/or ablation, mucosa of inferior turbinates, unilateral or bilateral, any method; 010 superficial Lavage by cannulation; maxillary sinus (antrum 010 puncture or natural ostium) Lavage by cannulation; sphenoid sinus (antrum 010 puncture or natural ostium) Nasal endoscopy, diagnostic, unilateral or bilateral 000 (separate procedure) Nasal/sinus endoscopy, surgical; with biopsy, 000 polypectomy or debridements (separate procedure) Nasal/sinus endoscopy, surgical; with concha bullosa 000 resection Nasal/sinus endoscopy, surgical; with ethmoidectomy, 000 partial (anterior) Nasal/sinus endoscopy, surgical; with ethmoidectomy, 000 total (anterior and posterior) Nasal/sinus endoscopy, surgical, with maxillary 000 antrostomy Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary 000 sinus Nasal/sinus endoscopy, surgical with frontal sinus exploration; with or without removal of tissue from 000 frontal sinus Nasal/sinus endoscopy, surgical, with sphenoidotomy
000
Nasal/sinus endoscopy, surgical, with sphenoidotomy;
000 with removal of tissue from the sphenoid sinus Nasal/sinus endoscopy, surgical; with dilation of maxillary sinus ostium (e.g. balloon dilation), 000 transnasal or via canine fossa With dilation of frontal sinus ostium (e.g. balloon 000 dilation) With dilation of sphenoid sinus ostium (e.g. balloon 000 dilation) MKT01941 Rev E ©2014 Acclarent, Inc. All rights reserved. Last Updated: January 2014 Relative Value Units (RVUs) 2014 National Average Medicare Allowable (No geographic adj.) Facility
Non‐Facility Payment Payment Facility Total Non‐Facility Total 12.54 12.54 $449 $449 39.17
39.17 $1,403
$1,403
17.82 17.82 $638 $638 3.91 6.49 $140 $232 3.00 5.20 $107 $186 5.74 5.74 $206 $206 1.85 5.92 $66 $212 4.65 7.35 $167 $263 4.64 4.64 $166 $166 7.85 7.85 $281 $281 11.50 11.50 $412 $412 5.68 5.68 $203 $203 9.12 9.12 $327 $327 14.52 14.52 $520 $520 6.68
6.68 $239
$239
7.74 7.74 $277 $277 4.80 58.74 $172 $2,104 5.74 59.62 $206 $2,136 4.72 58.64 $169 $2,101 42830 42831 42835 42836 Adenoidectomy, primary, younger than age 12
Adenoidectomy, primary, age 12 or over Adenoidectomy, secondary, younger than age 12
Adenoidectomy, secondary, age 12 or over
090
090
090
090
6.03
6.48
5.17
6.98
6.03 6.48 5.17 6.98 $216
$232
$185
$250
$216
$232
$185
$250
Related CPT / HCPCS Modifiers Description Modifier Bilateral Procedure: When bilateral procedures are performed in the same session, append the additional procedure. ‐50 ‐51 ‐53 ‐73 ‐74 50% payment reduction of the second procedure generally applies.
Multiple Procedures: When multiple procedures, other than E/M Services are performed at the same session by the same provider, append the additional procedure or service code(s). Use of ‐51 is not required by all payors.
Discontinued Procedure: Under certain circumstances, the physician may elect to terminate the procedure.
Discontinued Outpatient Hospital/Ambulatory Surgery (ASC) Procedure PRIOR TO the Administration of Anesthesia
– Applied when extenuating circumstances require the cancellation of a procedure. Discontinued Outpatient Hospital/Ambulatory Surgery (ASC) Procedure AFTER Administration of Anesthesia –
Applies when extenuating circumstances require the cancellation of a procedure. PHYSICIAN PROFESSIONAL PAYMENT EXAMPLE The following case example is based upon the 2014 Medicare Physician Fee Schedule. In this example, a patient undergoes a procedure including bilateral maxillary sinus balloon dilation and bilateral frontal sinus balloon dilation. The coding and national Medicare average payments reflect a procedure in which a balloon is the only tool used and no tissue is removed. Per AMA and AAO‐HNSF guidance, when balloons are used as a tool in ESS surgery and when tissue is removed, the traditional ESS codes should be used (see: http://www.entnet.org/Practice/Balloon‐Dilation.cfm). CPT Codes 31296‐50 Nasal/sinus endoscopy, surgical; with dilation of frontal sinus ostium (e.g. balloon dilation) 31295‐50‐51 Nasal/sinus endoscopy, surgical; with dilation of maxillary sinus ostium (e.g. balloon dilation) Total Estimated Medicare Allowable:
NOTES 2014 Estimated Medicare Allowable
NON‐FACILITY (Physician Office – POS 11) 2014 Estimated Medicare Allowable
FACILITY (ASC ‐ POS 24 or Hospital ‐ POS 22) $2,136 x 150% = $3,204 $206 x 150% = $308 ($2,104 x 150%) x 50% = $1,578 ($172 x 150%) x 50% = $129 $4,782 $437 Not all codes provided are applicable for the recommended uses of Acclarent products. The most appropriate code for the patient’s clinical presentation must be selected. CPT Copyright 2013 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. Sources: Calendar Year 2014 Medicare Physician Fee Schedule, Final Rule. Federal Register, December 10, 2013. Incorporates changes and updates from the Pathway for SGR Reform Act of 2013, December 26, 2013. No geographic adjustments have been made to the reported payment rates. Multiple surgery payment amounts based on guidance provided in the Medicare Claims Processing Manual, Chapter 12, 40.6. DISCLAIMER The information contained in this guide is provided to assist you in understanding the reimbursement process. It is intended to assist providers in accurately obtaining reimbursement for health care services. It is not intended to increase or maximize reimbursement by any payer. We strongly suggest that you consult your payer organization with regard to local reimbursement policies. The information contained in this document is provided for information purposes only and represents no statement, promise or guarantee by Acclarent concerning levels of reimbursement, payment or charge. Similarly, all CPT & HCPCS codes are supplied for information purposes only and represent no statement, promise or guarantee by Acclarent that these codes will be appropriate or that reimbursement will be made. MKT01941 Rev E ©2014 Acclarent, Inc. All rights reserved. Last Updated: January 2014 FOR ADDITIONAL QUESTIONS OR INFORMATION, CONTACT: [email protected] (877) 340‐6466

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