Chapter 34. Coding
Brief History: The fourth edition of Current Procedural Terminology (CPT, 2011 modification)1 was developed by the American Medical Association (AMA) and was published for first use in 1966. Its initial purpose was unrelated to reimbursement; it was developed as a type of medical shorthand for documenting and recording procedures. In 1983, the Health Care Financial Administration (HCFA) mandated that CPT be used as a standardized method for Medicare billing. This was extended to include Medicaid billing in 1986. Major insurers soon began to mandate its use, and would reject any medical claims not using CPT coding.2
Purpose of CPT coding: Today, CPT coding is a standardized means by which a medical provider most accurately describes procedures performed. It may be used as a tool for documentation alone, as with purely aesthetic procedures. More commonly, it must be used as a communication tool to health insurers to accurately document procedures performed and to obtain appropriate reimbursement.
The International classification of diseases3 (ICD) originated in seventeenth-century England, and its current ninth revision (ICD-9) is used to describe medical diagnoses. Using the most specific ICD-9 code(s) matching the specific CPT code(s) of the procedures (to be) performed is the best way to communicate what was done, and for what reason. Insurers will deny payment for viable claims if the ICD-9 code does not match the CPT code.
Cosmetic vs. reconstructive surgery: In 1989, the AMA adopted the following definitions of cosmetic and reconstructive surgery, which is reiterated in the American Society of Plastic Surgeons (ASPS) Recommended Insurance Coverage Criteria for Third-Party Payers. Cosmetic surgery is performed to reshape normal structures of the body in order to improve the patient’s appearance and self-esteem. Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance.4
The treating physician must carefully assess the potential patient to determine whether the proposed procedure is purely elective and aesthetic, purely reconstructive, or a combination of cosmetic and reconstructive procedures.
Combined cosmetic and reconstructive procedures: When rhinoplasty has both cosmetic and functional components, it is always important to preauthorize the procedures in writing, to be sure to distinguish which components are reconstructive (both preoperatively and in a single operative dictation), and to not bill the carrier for the cosmetic components.5 It is worthwhile to quote the AMA definitions above in the preauthorization request. Similarly, it is recommended that the cosmetic and reconstructive portions are clearly itemized for the patient in writing. The patient should understand the cost of the cosmetic component as well as any deductibles, coinsurances, and balances above and beyond the usual and customary reimbursement for the reconstructive portion.
Elective aesthetic rhinoplasty: CPT coding for elective, purely aesthetic rhinoplasty may be used for documentation of the type and extent of the procedure for the physician’s medical records. Practices may use and analyze this documentation for practice management, procedure trends, combined procedure analysis, and marketing. Although not mandated, the use of aesthetic rhinoplasty codes in combination with functional CPT codes may serve to fully document which portions of a combined procedure are aesthetic and non-reimbursable and which portions are functional and reimbursable.
When ICD-9 coding is necessary, V50.1 (plastic surgery for unacceptable cosmetic appearance) may be used.
CPT codes may be used to document the various types and extent of aesthetic rhinoplasty. Primary rhinoplasty implies no prior nasal surgery. Secondary rhinoplasty implies prior nasal surgery by the treating surgeon or by another surgeon.
Reconstructive rhinoplasty and related procedures: It is imperative that any and all proposed reconstructive rhinoplasty and related procedures be preauthorized by the involved health insurance carrier in writing prior to performing such procedures. CPT codes for rhinoplasty do not and cannot directly indicate whether the procedure is cosmetic or reconstructive. Most rhinoplasty CPT codes may be construed as cosmetic in nature, so complete documentation of the reconstructive nature of the proposed procedures must be conveyed to the carrier and acknowledged as reimbursable. Both primary and secondary rhinoplasty codes not only describe procedures performed electively for correction of primary nasal deformities and post-rhinoplasty deformities, respectively, but they may be used to report treatment of an array of functional and/or reconstructive nasal problems. In the event that any of the above procedures are performed for functional reasons, appropriate pre-procedure authorization as well as post-procedure documentation of the extent and nature of the procedure performed must accompany any insurance billing.
The following ICD-9 codes, which are not meant to be fully inclusive, may be used to describe the most common functional problems in reconstructive rhinoplasty (Table 34-1):