In November 2009, the Centers for Medicare and Medicaid Services (CMS) proposed to change the Correct Coding Institute (CCI) modifier edit for the CPT code pair of 30520 – Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft and 30801 – Ablation, soft tissue of inferior turbinates, unilateral or bilateral, any method (eg, electrocautery, radiofrequency ablation, or tissue volume reduction); superficial to disallow reimbursement when the two were reported together on the same DOS. If finalized this edit would have been effective from April 1, 2010.
In our comment letter to CMS regarding the proposed edit, we argued that, inferior turbinates and the septum are anatomically independent structures within the nose and each may contribute to airway obstruction. If both 30520 and 30801 were performed on the same date of service, it would generally be to correct separate causes of obstruction, for example septal deviation and obstructive inferior turbinate hypertrophy/hypertrophic rhinitis respectively. These are two different diseases in different anatomic sites within the nasal cavity, each contributing to nasal obstruction. Clinically, the work of 30801 is not part of septoplasty.
In its response, CMS agreed with our rationale and decided that physicians who perform 30520 and 30801 on the same DOS would be allowed to append an appropriate modifier, typically 59, to 30801 to show both services were different and separate. Many would argue that no modifier should be necessary for this code pair, but CMS raised concerns about 30801 being used for access or for hemostasis, thus the need to report a modifier. The CMS states, “CPT code 30801 should not be reported with CPT code 30520 if the cautery/ablation of the inferior turbinates is for the purpose of controlling bleeding due to the procedure described by CPT code 30520.” Coders should link different diagnosis codes to each CPT code. This article applies to Medicare contractors; you will want to check with private payers to verify whether they will follow these guidelines.
Approved April 2010
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.