CPT Code 43239 Esophagogastroduodenoscopy

43239 Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple

43239 with biopsy, single or multiple 

GI Procedures

EGD Procedures 

• Use code 43235 for a Diagnostic EGD procedure. Since this is classified as a “Separate Procedure” in the CPT book, it is not billable when a more extensive EGD procedure is performed.

• Two Upper Gastrointestinal Endoscopy procedures such as code 43239 for Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with biopsy, single or multiple and code 43245 for Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum, as appropriate; with dilation of gastric outlet for obstruction (e.g., balloon, guidewire, bougie) performed at the same setting would both be billable.

• If an EGD is done to collect a specimen for a CLO/H. Pylori test, since the test involves obtaining a tissue biopsy through the endoscope, the 43239 Biopsy code should be used. If the test is positive, the diagnosis code 041.86 for Helicobacter pylori (H. pylori) infection would be billed.

• If an EGD is performed with a biopsy, and then the physician removes the scope and performs an Esophageal Dilation by unguided sound, it should be billed using two CPT codes – CPT code 43239 for the scope with biopsy and code 43450 for the Esophageal Dilation would both be billed.

• Use CPT code 43248 if the patient has an EGD procedure with a flexible-tipped guidewire passed through the endoscope, the endoscope is withdrawn and the guidewire is left in place for dilators to be passed over the guidewire to dilate the Esophagus. If the guidewire is passed under fluoroscopic guidance for esophageal dilation, without the use of an endoscope, use CPT code 43453. 

• The control of bleeding is included in biopsy (and most other) endoscopic procedures, and is not separately-billable. Control of bleeding can be obtained through means of injections, as well as cauterizations. Injections of Epinephrine through an endoscope are coded as 43255. This injection would be included in the ASC facility fee, and would not be reimbursed separately from the EGD procedure, unless the EGD case is completed and the patient is in the PACU and has a bleed, necessitating a return to the OR to treat the hemorrhage. 

• For an EGD with a Polypectomy done by Cold Biopsy Forceps, use the 43258 Ablation code – not the 43239 Biopsy code. 


Endoscopy codes

Question and Answer Forum

Question: Do codes 43239 and 43255 require modifier 59? Which do I bill first, and to which code do I attach the modifier?

Answer: If the primary purpose of the endoscopy was control of bleeding, and a separate lesion/site was found, which required biopsy, then 43255 would be reported first; 43239 with 59 modifier would be reported for the second service, which would otherwise be bundled (i.e., biopsy of the bleeding site would not be separately reportable). If bleeding resulted from biopsy of a lesion and the treatment was for this purpose, the bleeding control would be considered part of the procedure (43239) and thus, 43255 would not be separately reported.

Unbundling occurs when multiple procedure codes are submitted for a group of procedures that are described by a single comprehensive code. An example of Unbundling would be fragmenting one service into component parts and coding each component as if it were a separate service. For example, the correct CPT comprehensive code to use for upper gastrointestinal endoscopy with biopsy of stomach is CPT code 43239. Separating the service into two component parts, using CPT code 43235 for upper gastrointestinal endoscopy and CPT code 43600 for biopsy of stomach is inappropriate (per CMS National Correct Coding Policy Manual).

Q: Can we code a 43239 with a 43249? I'm not sure if 43239 is included in 43249.

A: CPT guidelines permit the reporting of multiple endoscopy codes as appropriate. Codes 43239 and 43249 describe distinctly different procedures and should not be bundled by the payers. Both codes however include an upper GI endoscopy and payment adjustments should be expected for the duplicative portion. The issue becomes one of bundling - that is, is one code "bundled" in another by the payer? With the exception of Medicare, each carrier (Cigna, Aetna, Humana, etc.) has its own edits regarding bundling. There is no "national" bundling book for us to check in other than Medicare's Correct Coding Initiative (CCI). Under the CCI, these procedures are not bundled. I suggest that you report both services and monitor the EOB. If they are denied, I would appeal by referring to the distinct nature of the services and the CCI. It is helpful to have distinct ICD-9 codes (if appropriate) for the services to support the need for both of them on the same patient.

Upper GI Endoscopy with Biopsy CPT - 43239 

Modifier 33

Modifier 33: Preventive service; when the primary purpose of the service is the delivery of an evidence based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be identified by adding 33 to the procedure. For separately reported services specifically identified as preventive, the modifier should not be used.
The following list(s) of procedure and/or diagnosis codes is provided for reference purposes only and may not be all inclusive. Listing of a code in this guideline does not imply that the service described by the code is a covered or noncovered health service. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Other Policies and Coverage Determination Guidelines may apply.
Modifier 33
UnitedHealthcare considers the procedures and diagnostic codes and Preventive Benefit Instructions listed in the table below in determining whether preventive care benefits apply. While modifier 33 may be reported, it is not used in making preventive care benefit determinations.
Definitions Section: Added definition of Modifier 33.
Coding Section:
 Added Modifier 33 statement.
 Osteoporosis Screening:
o Updated USPSTF ‘B’ rating description to align with January 2011 USPSTF Recommendation Statement.
o Deleted the “C” rating that was part of the previous USPSTF Recommendation Statement.
 Screening for Visual Impairment in Children:
o updated USPSTF ‘B’ rating description to align with January 2011 USPSTF Recommendation Statement.
 Code Descriptions Updated:
o 82952 and G0437 (Updated descriptions are effective 1/1/11.)
 Codes Added:
o Abdominal Aortic Screening: 76700, 76705
o Cervical Cancer Screening: P3000, P3001
o Hepatitis B Screening: 87340, 87341
o HIV Screening: ICD9 diagnosis code V73.89
o Wellness Examinations: 99461, S0610, S0612, S0613
o Behavior Counseling/Healthy Diet: S9470
 Codes Deleted:
o Immunizations: 90470 (Code was retro terminated back to 12/31/10.)
o Hepatitis B Screening: 87515, 87516, 87517
o HIV Screening: 87534, 87535, 87536, 87537, 87538, 87539
 Modifier 33 – Preventive Services: when the primary purpose of the service is the delivery of an evidence based service in accordance with a USPSTF A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be identified by adding 33 to the procedure. For separately reported services specifically identified as preventive, the modifier should not be used.
In addition, deductible is not applied to claim lines with HCPCS 00810 services that are billed with the PT modifier for services on or after January 1, 2015. The deductible is also not applied when the PT modifier is appended to at least either one of the CPT codes within the surgical range of CPT codes (10000-69999) or HCPCS codes G6018-G6028 on the claim for services that were furnished on the same date of service as the procedure. But, MACs will apply deductible and coinsurance to claim lines for HCPCS 00810 services billed without modifier 33 or modifier PT.
Tips for Billing CPT Modifier 33
The modifier 33 was created to aid compliance with the Affordable Care Act (ACA) which prohibits member cost sharing for defined preventive services for nongrandfathered health plans. The appropriate use of modifier 33 reduces claim adjustments related to preventive services and your corresponding refunds to members. Modifier 33 is applicable to CPT codes representing preventive care services. CPT codes not appended with modifier 33 will process under the member’s medical or preventive benefits, based on the diagnosis and CPT codes submitted.
Modifier 33 should be appended to codes represented for services described in the US Preventive Services Task Force (USPSTF) A and B recommendations, the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC), and certain guidelines for infants, children, adolescents, and women supported by the Health Resources and Services Administration (HRSA) Guidelines.
The CPT® 2016 Professional Edition manual shares the following information regarding the billing of modifier 33, “When the primary purpose of the service is the delivery of an evidence based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive mandates (legislative or regulatory), the service may be identified by adding 33 to the procedure. For separately reported services specifically identified as preventive, the modifier should not be used.”
Modifier 33
Tufts Health Plan accepts and recognizes the use of modifier 33 when billed with services on the U.S. Preventive Services Task Force List that have an A or B rating.
The American Medical Association created this modifier to allow providers to identify a preventive service for which patient cost sharing does not apply under the Patient Protection and Affordable Care Act, which prohibits patient cost sharing for non-grandfathered plans.
Modifier 33 is appropriate to use with a CPT code that is a diagnostic/treatment service being performed as a preventive service.

CPT Code 49585 Repair umbilical hernia

49585 Repair umbilical hernia, age 5 years or older; reducible

Hospital Outpatient Department

APC 5341

APC Description

Peritoneal and Abdominal Procedures (CPT codes: 49491, 49492, 49495, 49496, 49500, 49501, 49505, 49507, 49520, 49521, 49525, 49540, 49550, 49553, 49555, 49557, 49560, 49561, 49565, 49566, 49570, 49572, 49580, 49582, 49585, 49587, 49590, 49600)

Ambulatory Surgery Center

CPT CODE 

49495, 49496, 495ØØ, 495Ø1, 495Ø5, 495Ø7, 4952Ø, 49521, 49525, 4954Ø, 4955Ø, 49553, 49555, 49557, 4956Ø, 49561, 49565, 49566, 4957Ø, 49572, 4958Ø, 49582, 49585, 49587, 4959Ø, , 496ØØ

Anthem Blue Cross and Blue Shield Central Region Clinical Claim Edit

Subject: Repair of reducible umbilical hernia with closure of gastrocolic fistula

Coverage is subject to the terms, conditions, and limitations of an individual member’s programs or products and the edit criteria listed below. Please compare the claim's date of adjudication to the range of the edit in question. Prior versions, if any, can be found below. 

Description CODE : 49585

Rationale

Anthem Central Region bundles CPT 49585 as incidental to CPT 43880. The performance of an abdominal procedure includes the reimbursement for hernia repair. The CMS National Correct Coding Manual states:

“If a hernia repair is performed at the site of an incision for an open or laparoscopic abdominal procedure, the hernia repair (e.g., CPT codes 49560-49566, 49652-49657) is not separately reportable. The hernia repair is separately reportable if it is performed at a site other than the incision and is medically reasonable and necessary. An incidental hernia repair is not medically reasonable and necessary and should not be reported separately.”

Therefore, if 49585 is reported in conjunction with 43880 – only 43880 is reimbursed. 

CPT Codes

15830 Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy

15847 Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (e.g. abdominoplasty) (includes umbilical transposition and fascial placation)

49560 Repair initial incisional or ventral hernia; reducible

49561 Repair initial incisional or ventral hernia; incarcerated or strangulated

49585 Repair umbilical hernia, age 5 or older; reducible

49587 Repair umbilical hernia, age 5 or older; incarcerated or strangulated


INDEPENDENT BILLING REVIEW FINAL DETERMINATION 

Disputed Codes: Rev Codes 0250 x 4, 0271, 0272, 0370, 0710, CPT/HCPCS J7120, C1781, 49650, 49585, J0690, J1956, J2001 x 2, J2405, J2704, and J3010


ANALYSIS AND FINDING

Based on review of the case file the following is noted:

 ISSUE IN DISPUTE: Provider seeking contractual reimbursement for Rev Codes 0250 x 4, 0271, 0272, 0370, 0710, CPT/HCPCS J7120, C1781, 49650, 49585, J0690, J1956, J2001 x 2, J2405, J2704, and J3010 for date of service 04/30/2015.

 The Claims Administrator reimbursement rational: “Official Medical Fee Schedule,” and “contract indicated.”

Based on the aforementioned documentation and guidelines, additional reimbursement is indicated for Rev Codes 0250 x 4, 0271, 0272, 0370, 0710, CPT/HCPCS J7120, C1781, 49650, 49585, J0690, J1956, J2001 x 2, J2405, J2704, and J3010

BCBSIL Significant Edits - 49585

BCBSIL utilizes an automated code auditing system that is designed to review reported codes to ensure that the correct procedure codes are identified for reimbursement. Claims are audited to review for potential incorrect billing. The following codes represent those procedures that are reported in high volume and that are not separately payable when billed in conjunction with other procedures.

This service is incidental to primary procedure code. Payment is included in allowance for primary service. 

Procedure Code 49560

Repair initial incisional or ventral hernia; reducible 49560

Incarcerated or strangulated 49561  

Implantation of mesh or other prosthesis for open incisional or ventral hernia repair, or closure of debridement (use with 11004–11006, 49560–49566) +49568

Question: We’re having discussions in our surgical practice on a couple of issues related to complex hernia repair. 

1) My surgeon thinks he should be able to bill separately for placement of a xenograft during complex incisional hernia repair using dermal graft codes 15330- 15331. I think the skin graft codes are not appropriate for hernias. Who’s right?

2) When the surgeon does a component separation during the hernia repair, is it appropriate to report 15734?

Answer: To address your first question, both CPT and the American College of Surgeons (ACS) are pretty clear that it would not be appropriate to report an additional graft code when the surgeon places a xenograft mesh as part of an incisional hernia repair.

Here’s what CPT states: “With the exception of the incisional or ventral hernia repairs (codes 49560- 49566), the use of mesh or other prostheses is not separately reported. Therefore, if the ‘open hernia repair’ is for an incisional or a ventral hernia repair, then it would be appropriate to separately report code 49568, Implantation of mesh or other prosthesis for incisional or ventral hernia repair (List separately in addition to code for the incisional or ventral hernia repair).

From a CPT coding perspective, xenograft mesh is a type of mesh prosthesis appropriately reported with code 49568” (CPT Assistant, June 2008). ACS also warns you away from reporting the 15000 series codes for graft placement during hernia repair.

“All codes in the 15000 series were specifically created for burn wounds, and fall within the skin substitute/ integumentary section of the CPT Codebook,” ACS states in the November 2009 Bulletin of the American College of Surgeons.

“These codes are not intended to be used for abdominal wall fascial repair. More specifically, 15330, Acellular dermal allograft, trunk, arms, legs; first 100 sq cm or 1% of body area of infants and children, and 15430, Acellular xenograft implant first 10 sq cm or 1% body area of infants or children, are included in this skin substitute section and do not apply to reconstruction of the abdominal wall hernia.”

Coding a flap for component separation

CPT does not address whether it would be appropriate to separately report component separation during complex hernia repair, but ACS states that this would be appropriate. “Some general surgeons now perform component separation of the abdominal wall, where the oblique or transversalis muscles are incised lateral to the hernia and the rectus muscles are mobilized toward the midline, to facilitate wound closure,” the society states.

“For this operation, the use of code 15734, muscle, myocutaneous, or fasciocutaneous flap, trunk, would be appropriate.” ACS further advises its members to apply modifier 50 (bilateral procedure) to 15734 if performed on two sides of the body, and modifier 51 (multiple procedure) if performed through the same incision as the hernia repair. You’ll need to check payer policies to see how they handle these procedures. Two things to note:

• Medicare policy does not allow additional payment for 15734-50 – you’ll only receive payment for one unit of the code, even with the modifier.

• Code 15734 pays $1,315 (all fees par, not adjusted for locality), which is more than any of the incisional hernia repair codes, 49560-49568 (e.g., 49566 [repair recurrent incisional or ventral hernia; incarcerated or strangulated] pays $906.70).

Medicare policy directs you to append the 51 modifier to lesser-valued codes so the multi-procedure payment reduction will be applied to them. But if the primary reason for the surgery is the complex hernia and the flap procedure is supplemental, practices will need to decide whether that is truly appropriate.

Digestive System

CPT Codes 40000-49999

Correspondence Language Policy/Example Number 2.40000 – 
HCPCS/CPT procedure code definition

For example, the code descriptor for CPT code 45805 is “Closure of rectovesical fistula; with colostomy” and the code descriptor for CPT code 45800 is “Closure of rectovesical fistula;”. Therefore, based upon the code descriptors the procedure described by CPT code 45800 is a component of the procedure described by CPT code 45805, and CPT code 45800 is bundled into CPT code 45805.

Correspondence Language Policy/Example Number 3.40000 – CPT Manual or CMS manual coding instruction

For example, the CPT Manual instruction above CPT code 49491 states: “With the exception of the incisional hernia repairs (see 49560-49566) the use of mesh or other prostheses is not separately reported.” Therefore, CPT code 49568 (mesh implantation) should not be reported separately with CPT code 49505 (inguinal hernia repair)

Coding Guidelines

“The work associated with returning a patient to the appropriate post-procedure state is included in the post-procedure work.”

“Treatment of complications of primary surgical procedures is separately reportable with some limitations. The global surgical package for an operative procedure includes all intra-operative services that are normally a usual and necessary part of the procedure.

Additionally the global surgical package includes all medical and surgical services required of the surgeon during the postoperative period of the surgery to treat complications that do not require return to the operating room.

Thus, treatment of a complication of a primary surgical procedure is not separately reportable (1) if it represents usual and necessary care in the operating room during the procedure or (2) if it occurs postoperatively and does not require return to the operating room.

For example, control of hemorrhage is a usual and necessary component of a surgical procedure in the operating room and is not separately reportable. Control of postoperative hemorrhage is also not separately reportable unless the patient must be returned to the operating room for treatment. In the latter case, the control of hemorrhage may be separately reportable with modifier 78.”

“If a definitive surgical procedure requires access through diseased tissue (e.g., necrotic skin, abscess, hematoma, seroma), a separate service for this access (e.g., debridement, incision and drainage) is not separately reportable. For example, debridement of skin to repair a fracture is not separately reportable.”

“If removal, destruction, or other form of elimination of a lesion requires coincidental elimination of other pathology, only the primary procedure may be reported. For example, if an area of pilonidal disease contains an abscess, incision and drainage of the abscess during the procedure to excise the area of pilonidal disease is not separately reportable.”

“If a hernia repair is performed at the site of an incision for an open or laparoscopic abdominal procedure, the hernia repair (e.g., CPT codes 49560-49566, 49652-49657) is not separately reportable.

The hernia repair is separately reportable if it is performed at a site other than the incision and is medically reasonable and necessary. An incidental hernia repair is not medically reasonable and necessary and should not be reported separately.”

“If an endoscopic procedure is performed at the same patient encounter as a non-endoscopic procedure to ensure no intraoperative injury occurred or verify the procedure was performed correctly, the endoscopic procedure is not separately reportable with the non-endoscopic procedure.”

“By contrast, incidental services that are necessary to accomplish the primary procedure (e.g., lysis of adhesions in the course of an open cholecystectomy) are not separately reportable with an addon code. Similarly, complications inherent in an invasive procedure occurring during the procedure are not separately reportable.

For example, control of bleeding during an invasive procedure is considered part of the procedure and is not separately reportable.”

Medicare CPT 30140, 30802, 30930

Procedure Code 30140, 30802, 30930
procedure code  30802 -  Ablation, soft tissue of inferior turbinates, unilateral or bilateral, any method (eg. electrocautery,  radiofrequency ablation, or tissue volume reduction), intramural (ie. submucosal) Average fee payment  $195
procedure code  30140 -  Submucous resection inferior turbinate, partial or complete, any method - Average fee payment - $ 449
procedure code 30802 - is used for both unilateral or bilateral procedures and may be reported only once per operative session. Use of the phrase “any method” in the code definition indicates that the specific instruments and techniques used to accomplish the reduction do not alter the code assignment.
Intramural ablation of the turbinates includes any ablation of the  uperficial tissues so the code for superficial ablation (30801) is not assigned separately with 30802. procedure code 30140 is considered to be unilateral and would be billed with bilateral modifier-50.
INFERIOR TURBINOPLASTY WITH OUTFRACTURE
Turbinoplasty and outfracture are sometimes performed together. According to NCCI edits or procedure descriptions, procedure code 30930 should not be billed with 30140.
If procedure codes code 30802 and 30930 are reported together, only one code is paid unless procedures are performed independently on opposite sides.
HOSPITAL OUTPATIENT CODING AND PAYMENT
Hospitals use procedure codes to report outpatient services. Payment shown is for Medicare’s APC hospital outpatient prospective payment system and is the Medicare national average without geographical adjustment. Status Indicator “T” = significant procedure, multiple reduction applies.
Payment for each code is made at 100% of the rate when it is the only significant procedure billed.
When billed with another status T procedure with higher weight, payment for lower weighted procedures is reduced to 50% of the rate.
CMS Final 2015 Outpatient Rule - CMS-1613-FC. Fee schedules are national averages and are not geographically adjusted.
Status indicator “T” means “significant procedure, multiple procedure reduction applies”
NCCI edits apply to hospital coding as well as physician coding. If inferior turbinoplasty and outfracture are performed together on the same side, hospitals should report only 30930 for outfracture.
Multiple procedure discounting indicates that the procedures are subject to standard multiple procedure rules when performed together; one procedure is paid at 100% of the rate and the other is paid at 50% of the rate.
Payment Indicator A2 means “Surgical procedure with transitional payment based on hospital outpatient relative payment weight”
Fracture Nasal Inferior Turbinate(s), Therapeutic with Submucous Resection
Coverage is subject to the terms, conditions, and limitations of an individual member’s programs or products and the edit criteria listed below. Please compare the claim's date of adjudication to the range of the edit in question.
30930 Incidental 30140
30930-59 Separate Reimbursement 30140
Rationale
Anthem Central Region bundles 30930 as incidental with 30140, bundles 30930-50 as incidental with 30140-50, bundles 30930-LT as incidental with 30140-LT and bundles 30930-RT with 30140-RT.
Based on procedure Assistant, Coding Consultation: Questions and Answers article:
Respiratory System/Surgery, 30930, 30140 (Q&A)
Question
Is it appropriate to report procedure code 30930, Fracture nasal turbinate(s), therapeutic, when performed in conjunction with 30140, Submucous resection turbinate, partial or complete any method, on the same turbinate?
AMA Comment
From a procedure coding perspective, it is not appropriate to report procedure code 30930 with 30140 if performed on the same turbinate. In addition, 30930 should not be reported with ethmoid sinus surgery if relating to the middle turbinate. When reporting code 30140, the documentation in the operative report should reflect that the physician entered/incised the mucosa and, for the most part, preserved it.
The simple statement “excised the turbinate(s)” is often not enough documentation to reflect that the submucous resection of the inferior turbinate was performed. Coders may need to ask the physician for the specific technique performed.
Based on the National Correct Coding Initiative Edit, code 30930 is listed as a component code to code 30140. Therefore, if 30930 is submitted with 30140—only 30140 reimburses, if 30930-50 is submitted with 30140-50—only 30140-50 reimburses, if 30930-LT is submitted with 30140-LT—only 30140-LT reimburses, if 30930-RT is submitted with 30140-RT—only 30140-RT reimburses.
Anthem Central Region does not bundle 30930-59 with 30140 or does not bundle 30930-LT with 30140-RT. If the inferior turbinate is excised (30930) along with performing 30140, append modifier 59 to 30930 and both procedures reimburse separately (30930-59 and 30140).
If 30930 is performed on one side of the nose, append the appropriate modifier LT or RT to reflect the side where 30930 was  performed and if 30140 was performed on the opposite side, append other LT or RT modifier to show 30140 was performed on the other side.
Therefore, if 30930-59 is submitted with 30140—both services reimburse separately and if 30930-LT is submitted with 30140-RT—both services reimburse separately.
If on compliant/appeal it is documented that 30930 was performed on one side or was performed on the  inferior turbinate and 30140 was also performed--both procedures reimburse separately.
30802 - Ablation, soft tissue of inferior turbinates, unilateral or bilateral, any method (eg. electrocautery, radiofrequency ablation, or tissue volume reduction), intramural (ie. submucosal)
30140 - Submucous resection inferior turbinate, partial or complete, any method
30930 - Fracture nasal inferior turbinate(s), therapeutic
AMBULATORY SURGERY CENTER CODING AND PAYMENT
Medicare payment for procedures performed in an ASC are based on the APC methodology for hospital outpatient payment. CPT codes 30802 and 30930 are designated as ASC Covered Surgical Procedures for CY 2015.
30802 - Ablation, soft tissue of inferior turbinates, unilateral or bilateral, any method (eg. electrocautery, radiofrequency ablation, or tissue volume reduction), intramural (ie. submucosal)
30140 - Submucous resection inferior turbinate, partial or complete, any method
30930 - Fracture nasal inferior turbinate(s), therapeutic
30930 and 30140
Question:
Our surgeon wants to report CPT code 30930 every time he does an turbinate outfracture with his submucous resections (30140).I have explained that the outfracture is included but he disagrees. I talked to a peer in another practice and he told me that I can’t report it because there is a CCI edit in place.We code according to CPT rules, not Medicare payment rules, thus I would never use that as rationale in explaining to the surgeon why a code set is reportable together or not. Can KZA help with an explanation?
Answer:
Great question and thanks for reaching out to the Otolaryngology Coding Team. We checked with the team and our response follows.
In 2006, CPT revised the definition of CPT code of theturbinate codes to identify surgical procedures on the inferior turbinates only.
According to a citation in the CPT Changes: An Insider’s View, “CPT codes 30130, 30140, 30801, 30802, and 30930 have been revised to clarify their widespread usage specific to the inferior turbinates and primary reporting for procedures performed for the treatment of inferior turbinate hypertrophy causing nasal airway obstruction and to eliminate frequent confusion with middle and superior turbinates when other intra-nasal surgeries (e.g., endoscopic sinus surgery) are performed.
”Additionally, codes 30801, 30802, and 30930 were revised with the removal of “separate procedure” from the descriptors.
Cross-references were added in support of these revisions to indicate codes 30130 (partial or complete excision of turbinate bone) and 30140 (partial or complete submucous resection of turbinate bone), which report larger procedures for which removal of the inferior turbinates are inherent, would not be appropriately reported in conjunction with these codes.
” As a result of this rule change when the codes were revised to specifically address surgery on the “inferior” turbinates, the procedures became inclusive to each other.
Finally, the CPT guidelines listed directly underneath 30930 state “(Do not report 30801, 30802, 30930 in conjunction with 30130 or 30140)”.
Therefore, it is not appropriate to report 30930 with 30140 ever for procedures on the same turbinate. Just because there is a Medicare CCI column edit of “1” doesn’t mean it is appropriate to report both codes. You must understand CPT coding rules first.
Coding Guidelines
Treatment of Obstructive Sleep Apnea, B2002.13 R3
1. Oral appliances for obstructive sleep apnea must be billed to the appropriate DMERC using E1399.
2. Submucous radlofrequency reduction of hypertrophied turbinates should be Billed with CPT code 30140-30152.
3. If LAUP is billed for denial purposes, it should be coded as 42299, (unlisted procedure, palate, uvula) with "LAUP" listed in Item 19 on the CMS-1500 claim form or electronic equivalent. The claim will then be appropriately denied as not proven effective.
4. If SomnoplastyTM is billed for denial purposes, it should be coded as 42299, (unlisted procedure, palate, uvula) with "SomnoplastyTMII listed in Item 19 on the CMS-1500 claim form or electronic equivalent. This claim will then be appropriately denied as not proven effective.
5. The Pillar ProcedureTM should be billed as 42299 (unlisted procedure, palate, uvula) with "Pillar ProcedureTM" or "palatal implant" listed in Item 19 on the CMS-1500 claim form or electronic equivalent. This claim will then be appropriately denied as not proven effective.

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