Sinusitis also called rhinosinusitis or sinus infection is a common inflammation of the air cavities that produce the mucus necessary for the nasal passages to work properly. It is one of the more prevalent chronic illnesses in the United States and affects people of all ages. According to the Centers for Disease Control and Prevention (CDC), 26.5 million adults (11.0% of adults) were diagnosed with sinusitis in 2016. Sinusitis can be acute or chronic, and caused by viruses, bacteria, fungi, allergies, or even an autoimmune reaction. Surgery is generally recommended for chronic sinusitis when medical treatment fails. Frequently performed in an outpatient setting, functional endoscopic sinus surgery (FESS) is a minimally procedure used to restore sinus ventilation and normal function. There are new bundled FESS codes in 2018 and outsourcing medical coding can help providers understand the new codes and submit accurate claims for maximum reimbursement.
Chronic Rhinosinusitis (CRS) – Causes and Symptoms
While acute sinusitis usually occurs due to a bacterial infection and responds to antibiotics, chronic sinusitis triggers an aggressive inflammatory reaction and may not get better with conservative treatment. In CRS, the cavities around sinuses become inflamed and swollen for at least 12 weeks, and do not get better with treatment. Patient history is very important in CRS because sinus symptoms may be similar to that of other disease processes, and also due to the poor association between symptoms and endoscopic and radiographic findings.
Chronic sinusitis can be caused by an infection, by nasal polyps, or by a deviated nasal septum. Common symptoms are:
- Nasal obstruction, blockage, congestion, stuffiness
- Nasal discharge (which may be thin to thick and from clear to purulent)
- Postnasal drip
- Pain, tenderness and swelling around the eyes, cheeks, nose or forehead
- Chronic unproductive cough (especially in children)
- Hyposmia or anosmia (more with nasal polyps)
- Reduced sense of smell
- Sore throat
- Bad breath
- Fatigue or irritability
- Exacerbation of asthma
- Dental pain (upper teeth)
- Visual disturbances
- Sore throat
- Stuffy ears
Complications of a sinus infection that can occur include meningitis, brain abscess, osteomyelitis, and orbital cellulitis. Rare fungal infections of the sinuses are medical emergencies.
Diagnosis and Treatment
Symptoms must have been present for longer than 12 weeks for a diagnosis of chronic sinusitis. The following methods for diagnosing the condition:
- Examination of the nose and face for signs of tenderness
- Rhinoscopy (nasal endoscopy)
- Nasal and sinus cultures may be used to determine if the condition is caused by bacteria or fungi.
- An allergy skin test is done if thenasal flare up is suspected to be triggered by allergies
The goal of treating chronic sinusitis is to reduce the inflammation of the nasal passages and keep them draining, resolve the underlying cause, and reduce the incidence of sinusitis flare-ups. Primary treatments may include: saline nasal irrigation, nasal corticosteroids, corticosteroids, aspirin desensitization treatment, antibiotics, and immunotherapy. Functional endoscopic sinus surgery (FESS) could be an option for cases resistant to primary treatment.
Functional Endoscopic Sinus Surgery (FESS)
The goal of FESS is usually to remove obstructions that block natural drainage and also inflamed tissue and bone. FESS involves inserting an endoscope into the nose to evaluate the nasal anatomy, central airway, and sinuses. Abnormal and obstructive tissues are then removed or the septum straightened using state-of-the-art imaging technology and equipment. This less invasive surgical procedure is usually performed entirely through the nostrils, resulting in minimal post-operative discomfort, quicker healing.
The surgery may take from one to three or more hours, and the patient may receive general anesthesia or, sometimes, sedation through local anesthesia. Endoscopic sinus surgery can clear blockage with minimal disturbance to the healthy tissue and with no external scars.
Clinical Documentation to indicate Medical Necessity
For reimbursement, the clinical documentation must indicate the medical necessity of FESS. United Healthcare considers Functional endoscopic sinus surgery (FESS) as proven and/or medically necessary for one or more of the following:
- Patients with chronic rhinosinusitis (defined as rhinosinusitis lasting longer than 12 weeks) with both of the following:
- Chronic rhinosinusitis of the sinus to be operated on is confirmed on computed tomography (CT) scan by one or more of the following: Mucosal thickening; Bony remodeling; Bony thickening; Obstruction of the ostiomeatal complex, and Opacified sinus.
- Symptoms persist despite medical therapy with one or more of the following: Nasal lavage; Antibiotic therapy, if bacterial infection is suspected, and Intranasal corticosteroid
- Mucocele documented on CT scan
- Concha bullosa documented on CT scan
- Complications of sinusitis such as abscess
- Tumor documented on CT scan (such as polyposis or malignancy)
- Recurrent acute rhinosinusitis (RARS)
ICD Codes for sinusitis
ICD-10-CM sinusitis codes include diagnosis codes for acute recurrent sinusitis:
- B47.0 Eumycetoma
- C30.0 Malignant neoplasm of nasal cavity
- C31.0 Malignant neoplasm of maxillary sinus
- C31.1 Malignant neoplasm of ethmoidal sinus
- C31.2 Malignant neoplasm of frontal sinus
- C31.3 Malignant neoplasm of sphenoid sinus
- C31.8 Malignant neoplasm of overlapping sites of accessory sinuses
- C31.9 Malignant neoplasm of accessory sinus, unspecified
- D14.0 Benign neoplasm of middle ear, nasal cavity and accessory sinuses
- G96.0 Cerebrospinal fluid leak
- J01.01 Acute recurrent maxillary sinusitis
- J01.11 Acute recurrent frontal sinusitis
- J01.21 Acute recurrent ethmoidal sinusitis
- J01.31 Acute recurrent sphenoidal sinusitis
- J01.41 Acute recurrent pansinusitis
- J01.81 Other acute recurrent sinusitis
- J01.91 Acute recurrent sinusitis, unspecified
- J32.0 Chronic maxillary sinusitis
- J32.1 Chronic frontal sinusitis
- J32.2 Chronic ethmoidal sinusitis
- J32.3 Chronic sphenoidal sinusitis
- J32.4 Chronic pansinusitis
- J32.8 Other chronic sinusitis
- J32.9 Chronic sinusitis, unspecified
- J33.0 Polyp of nasal cavity
- J33.1 Polypoid sinus degeneration
- J33.8 Other polyp of sinus
- J33.9 Nasal polyp, unspecified
- J34.1 Cyst and mucocele of nose and nasal sinus
- J34.81 Nasal mucositis (ulcerative)
- J34.89 Other specified disorders of nose and nasal sinuses
- J34.9 Unspecified disorder of nose and nasal sinuses
- Q01.1 Nasofrontal encephalocele
- R04.0 Epistaxis
In 2018, new FESS codes have been introduced which bundle a total ethmoidectomy with both a frontal sinusotomy and a sphenoidotomy with and without removal of tissue. 2018 CPT also provides a new bundled code for frontal and sphenoid endoscopic balloon dilation:
- 31256-31288 Functional Endoscopic Sinus Surgery Family (previously 7 codes, now 11)
- 31295-31297 Balloon Sinuplasty Family (previously 3 codes, now 4)
- 31240 Nasal/sinus endoscopy, surgical; with concha bullosa resection
- 31253 Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including frontal sinus exploration, with removal of tissue from frontal sinus, when performed
- 31254 Nasal/sinus endoscopy, surgical with ethmoidectomy; partial (anterior)
- 31255 Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior)
- 31256 Nasal/sinus endoscopy, surgical, with maxillary antrostomy
- 31257 Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including sphenoidotomy
- 31259 Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including sphenoidotomy, with removal of tissue from the sphenoid sinus
- 31267 Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus
- 31276 Nasal/sinus endoscopy, surgical with frontal sinus exploration, including removal of tissue from frontal sinus, when performed
- 31287 Nasal/sinus endoscopy, surgical, with sphenoidotomy
- 31288 Nasal/sinus endoscopy, surgical, with sphenoidotomy; with removal of tissue from the sphenoid sinus
Balloon Sinus Dilation Codes
- 31295 Nasal/sinus endoscopy, surgical; with dilation of maxillary sinus ostium (e.g., balloon dilation), transnasal or canine fossa
- 31296 Nasal/sinus endoscopy, surgical; with dilation of frontal sinus ostium (e.g., balloon dilation)
- 31297 Nasal/sinus endoscopy, surgical; with dilation of sphenoid sinus ostium (e.g., balloon dilation)
- New/Bundled 31298 Nasal/sinus endoscopy, surgical; with dilation of frontal and sphenoid sinus ostia (e.g., balloon dilation)
New Sphenopalatine Artery Code
- 31241 Nasal/sinus endoscopy, surgical; with ligation of sphenopalatine artery
FESS Coding Guidance
An AAPC article on FESS coding provides some important guidance about FESS coding. To a question on coding when all four sinuses are operated on the same side (with no removal of tissue), expert physicians advised:
- using CPT codes 31253, 31287, 31256 or 31257, 31276, 31256 to code all four sinuses
- If tissue is removed, 31287 and/or 31256 should be replaced with 31288 and/or 31267 in the first coding combination or 31257 and/or 31256 should be replaced with 31259 and/or 31267
Partnering with an experienced otolaryngology medical billing and coding company is the best way to manage the challenges associated with reporting office visits as well as for surgical procedures related to disorders and diseases of the ear, nose, and throat. Experienced medical coders will review medical records carefully to assign the right codes and ensure maximum reimbursement for otolaryngology services.
Pharyngitis is the inflammation of the pharynx which is located at the back of the throat. Often referred to as sore throat, this condition causes discomfort, pain or scratchiness in the throat leading to difficulty in swallowing. Pharyngitis can involve some or all parts of the throat such as – the back part of the tongue, the soft palate (roof of the mouth) and the tonsils (fleshy tissue that are part of the throat’s immune defenses). This condition, in most cases is present because of another illness such as cold, flu or mononucleosis. According to the American Osteopathic Association (AOA), pharyngitis-induced sore throat is one of the most frequent reasons for physician visits. More cases of this condition occur during the colder months of the year. One of the most common causes of sore throat is infection with bacteria or viruses such as the common cold, influenza, or mononucleosis. Quick diagnosis of the root causes and symptoms of sore throat is essential for healthcare providers to give proper treatment for the same. Accurate documentation is crucial to ensure appropriate care, and medical coding outsourcing is an ideal option for physicians to streamline their documentation process.
What Are the Symptoms of Pharyngitis?
The main symptom of pharyngitis is a sore throat and pain with swallowing. The other signs and symptoms may vary depending on the type and severity of the underlying condition and may include –
- Joint pain and muscle aches
- Skin rashes
- Swollen lymph glands in the neck
- Severe fatigue
- General malaise
- Loss of appetite
In addition, frequent exposure to colds and flus can potentially increase the risk for this throat condition. Allergies, smoking and exposure to second-hand smoke may also raise your risk.
Diagnosing and Documenting Pharyngitis
For those experiencing symptoms of pharyngitis, physicians will generally check for any white or grey patches, swelling and redness. They will also feel the sides of the neck to check for a swollen lymph. In some cases, a complete blood count (CBC) test may be done to determine if you have another type of infection. In addition, a throat swab test will be recommended by the physician wherein the doctor rubs a sterile swab over the back of the throat to get a sample of secretions. The sample will be further checked to identify the presence of streptococcal bacteria, the cause of strep throat. Typically, a sore throat (caused by a viral infection) may last for five to seven days and doesn’t require any medical treatment. However, to ease pain and fever, many people turn to acetaminophen (Tylenol, others) or other mild pain relievers. On the other hand, if the sore throat is caused by a bacterial infection, physicians will prescribe antibiotics.
Treatment for pharyngitis mainly focuses on reducing symptoms and understanding the risk factors so that people can live their life as normal as possible. Accurately diagnosing the condition and submitting proper clinical documentation helps in promoting error-free billing practices. Relying on the services of a professional medical coding company can ensure this. ICD-10 codes for diagnosing this disorder include –
- J02 – Acute pharyngitis
- J02.0 – Streptococcal pharyngitis
- J02.8 – Acute pharyngitis due to other specified organisms
- J02.9 – Acute pharyngitis, unspecified
- J31.1 – Chronic nasopharyngitis
- J31.2 – Chronic pharyngitis
Regardless of the causes of sore throat, there are several home-care strategies that can help ease your symptoms. Maintaining proper hygiene can prevent most cases of this disease. Preventing bacterial infections can help reduce the spread of infections. Giving adequate voice rest and avoiding exposure to secondhand smoke can help prevent spreading this condition.
Costly chronic conditions of ICD-10-CM have been classified by CMS into Hierarchical Conditional Categories (HCCs). Patients with HCC conditions require more resources and disease intervention. The Risk Adjustment process identifies patients who are more costly to care for based on the diagnosis codes billed for the patient in the previous review period. Proper HCC coding and documentation is critical for health care providers participating in risk-adjusted market of Accountable Care Organizations (ACOs), Medicare’s Hospital Value Based Program (HVBP), or Medicare Advantage (MA).
Medicare wants payments to CMS-accepted organizations to be in line with the expected cost of care. To this end, CMS targets health plans with both random and targeted audits to confirm validity of diagnoses submitted. Submitting an inaccurate diagnosis or a diagnosis resulting in a different HCC poses a major compliance risk and will lead to payment recovery to Medicare. Any change in the HCC could mean that the provider is receiving too much or too little revenue. In both cases, the code would be considered invalid or discrepant.
To stay compliant and mitigate risk of audits, healthcare providers must be well aware of the essentials that should be present in the medical record. One of the most critical and basic requirements is proper documentation of the diagnosis to capture the most accurate HCC code. For this, documentation should indicate the diagnoses being monitored, evaluated, assessed/addressed, or treated (M.E.A.T.).
M.E.A.T. stands for: M-monitoring, E-evaluating, A-assessing, and T-treatment. M.E.A.T. is at the heart of HCC coding and clinical documentation and is defined as follows:
- Monitor-signs, symptoms, disease progression, disease regression
- Evaluate-test results, medication effectiveness, response to treatment
- Assess/Address-ordering tests, discussion, review records, counseling
- Treat-medications, therapies, other modalities
These four factors help providers to establish the presence of a diagnosis during an encounter and ensure proper documentation. For medico-legal purposes, complete documentation provides evidence of a diagnosis, that is, “if it was not documented, it does not exist”.
For success with documentation, clinicians should make sure it adheres to M.E.A.T. guidelines. If M.E.A.T. is not documented to validate the diagnosis, the diagnosis will be rejected by CMS due to the lack of evidence by provider. The following is an example of supported documentation:
Congestive Heart Failure (CHF) – 150.3, symptoms well controlled with Lasix and ACE inhibitor. Will continue current medications”
To indicate HCC diagnosis, providers should:
- Code all documented conditions that co-exist at the time of the encounter that require patient care, treatment, and management
- Fully document and accurately code the evaluation and ongoing management of all severe and chronic conditions
- Document history of heart attack, status codes, etc.
- Document diagnoses as “history of” or “PMH” only when they no longer exist or are not a current condition
- Ensure that each note has date, signature and credentials
Medicare focuses on these diagnoses to demonstrate the need for higher reimbursement rates for patients who have more serious conditions or problems to manage. If the ICD-10 code on the claim is not accurate or complete, this would indicate that the provider did much less work (medical decision making, evaluation, and management) than actually performed, leading to lower reimbursement.
Today, the demand for increased specificity under ICD-10 and the growing use of HCCs is driving health care organizations to enhance their clinical documentation improvement (CDI) efforts. While it is up to the physician to accurately, completely, and legibly documenting the services performed, collaborating with a medical coding company with experience in HCC coding would ensure accurate code assignment and proper reporting of diagnoses and procedures. Partnering with the right medical billing and coding company will help providers:
- Take advantage of Medicare risk adjustment coding opportunities by capturing the most appropriate HCC codes
- Ensure that all HCC codes reported on the encounter claim are supported by M.E.A.T.
- Ensure accurate quality measures
- Boost financial integrity
With their expertise in executing risk adjustment and HCC auditing, a reliable medical coding service provider and can help health care organizations minimize compliance risks, enhance care delivery, and improve data integrity with appropriate diagnostic reporting.
Anesthesia reimbursement comes with unique challenges, as experienced medical billing and coding companies know. A recent Department of Veteran Affairs (VA) ruling puts the spotlight on the providers of anesthesia services and can also affect CRNA medical billing.
Anesthesiologists and Certified Registered Nurse Anesthetists (CRNA) face medical billing issues related to cancelled anesthesia, failed medical direction, monitored anesthesia care, time issues, invasive line placement rules, and start/stop times. Anesthesiologists have to adhere to stringent federal guidelines andwatch out for even minor errors documentation errors which can lead to overbilling. ICD-10 has brought about many changes for the anesthesiology specialty and specificity in clinical documentation is the key to proper coding for maximum reimbursement. Payment also depends on the correct use of modifiers.
There are specific rules for CRNA medical billing based on the setting in which services are provided. The anesthesia modifier on the CRNA claim informs the insurance company that the CRNA was medically directed. CRNAs can bill the Medicare program either:
- Directly for services using their National Provider Identifier (NPI) or
- Under the NPI of a hospital, physician, group practice, or ASC with which they are employed in or contracted
Time and modifiers are crucial components in anesthesia medical billing and coding. Anesthesia time is the continuous period that begins when the patient is prepared for anesthesia services in the operating room or equivalent area and ends when the patient may be placed safely underpostoperative care. Time blocks can be included around an interruption in anesthesia time as long as continuous anesthesia care is furnished within thetime periods around the break.
Anesthesia billing modifiers include:
- QS – Monitored anesthesia care service
- QY – Medical direction of one certified registered nurse anesthetist by an anesthesiologist
- QZ – CRNA service: without medical direction by a physician
- QX – CRNA service: with medical direction by a physician
Failing to document relief times could cause a compliance problem. Anesthesiologists cannot relieve Certified Registered Nurse Anesthetists (CRNAs) that they are medically directing. Best practices require that the CRNA has to relieve a CRNA and an MD has to relieve an MD.
MedPage reported on the VA’s new rule which states that the CRNAs will not be able to independently administer anesthesia. However, the VA’s amended medical regulations permit full practice authority of three roles of VA advanced practice registered nurses (APRN) – certified nurse-midwives, nurse practitioners, and clinical nurse specialists – when they are acting within the scope of their VA employment. These APRNs will be able to practice “without the clinical supervision or mandatory collaboration of physicians.”
Certified registered nurse anesthetists are a vital component in the US healthcare system. In addition to the healthcare facilities of the military, public health services and Department of Veteran Affairs, CRNAs deliver anesthesia care in traditional hospital surgical suites, obstetrical delivery rooms, critical access hospitals, ambulatory surgical centers, and the offices of dentists, podiatrists, plastic surgeons and pain management specialists.
Leaving CRNAs out of the new VA policy has come in for much debate. The American Medical Association’s Board of trustees has expressed disappointment with the proposal and urged the VA to maintain the physician-led model within the healthcare system to ensurecoordination of care for veterans.The AMA says that administration of anesthesia requires physician leadership for patient safety, and does not support the ruling that the other advanced nurse categories will be able to practice independently.
The American Society of Anesthesiolgy (ASA) has supported the decision to withhold full authority from the CRNAs on the grounds that veterans have multiple medical conditions that increase risk of complications during and after surgery and anesthesia. The ASA, however, commends the role of CRNAs in the operating room.
The American Association of Nurse Anesthetists (AANA) is understandably disappointed with the new VA rule and recommends thatall advancedadvance practice nurses, including CRNAs, be granted full practice authority.
MedPage reports that the AANA president said, “We, as advance practice registered nurses (APRNs), all realize we’re ready and capable [of providing] the services that are necessary for our veterans today.”
Clinical documentation improvement (CDI) solutions along with accurate medical billing and coding services are now critical for healthcare specialists to eliminate gaps in the reimbursement and revenue cycle. According to a survey by Black Book Research, 90% of US hospitals report they gained at least $1.5M in healthcare revenue after implementing clinical documentation improvement.
In this survey of 907 healthcare leaders, it was found that hospitals enhanced quality of care and the organization’s bottom line by using the CDI programs after the ICD-10 transition.
Key findings of the report are –
- Since the ICD-10 launch date, the number of community and large hospitals contracting for external CDI solutions nearly doubled
- Approximately 85 percent of hospitals experienced quality improvements and case mix index increases after CDI implementation
- Because of its potential to increase healthcare revenue and optimize high-value specialist utilization, 87% hospital financial officers consider the case mix index improvement as the largest motivator for CDI adoption
- 88 percent of hospital and physician financial executives are actively trying to link care with analytics and outcomes to support healthcare consumerism and shift to value-based payments through vendor solutions.
- 76 percent of hospitals that have not adopted CDI programs stated that CDI has risen to the top of 2017 budget priority lists, especially since ICD-10 implementation is over.
- Because of physician acquisitions and EHR replacement projects, many healthcare providers are now considering CDI and coding solutions replacement.
Though EHRs certainly play a key role in the industry, the survey reports that half of acute care respondents were not confident that their EHRs effectively captured the patient data to meet developing clinical documentation needs for population health and big data initiatives.
According to the lead author of the study, “CDI is a key step in dramatically improving operational efficiency in healthcare organizations. Failing to address flaws in documentation processes has resulted in higher incidences of errors, financial losses and diminished patient care, and struggling hospitals will not survive on that old path.”
As clinical documentation is at the core of every patient encounter, the demand for successful CDI programs offered by experienced medical coding companies has increased now.