More from November 2013 - Vol. 32 No. 11
Stephen Nogan, MD
Ohio State University
On September 7, 2013, I returned from a one-week surgical mission trip to Guaimaca, Honduras, thanks in no small part to the support I received from the American Academy of Otolaryngology—Head and Neck Surgery Foundation. It was a highly successful trip with many patients treated, and the experience laid the groundwork for future international missions in my own career.
My first glimpse into international surgical missions came at the age of 20 during my undergraduate studies. I traveled into a Mexican village with 100 strangers and no clear career path, and I left at the end of the trip with many new friends and mentors and a determination to pursue a career in surgery. One of those new friends was David S. Parsons, MD, a pediatric otolaryngologist from Charlotte, NC, whom I joined on several subsequent trips to Mexico and who was the team captain for my recent trip to Honduras.
Guaimaca is a municipality in the department (state) of Francisco Morazán in the central part of the country. Honduras has more than 8 million people, more than 50 percent of whom are living under the poverty line and more than 25 percent of whom are unemployed. Guaimaca is no exception to these national statistics. Within Guaimaca exists a hospital, Hospital Bautista, on a mission compound built with private donations and equipped with four brand new operating rooms that Dr. Parsons, Harvey M. Tucker, MD, Robert A. Willis, MD, Christopher L. Tebbit, MD, Tabitha L. Galloway, MD, and I were the first to use.
We performed approximately 65 surgeries over the course of four days and distributed hundreds of medications. The operating rooms were fully staffed by U.S. volunteers, and we received additional, incredible support from Honduran physicians, nurses, translators, and security guards throughout the week. Operations included tonsillectomies, adenoidectomies, septoplasties, endoscopic sinus surgery, endoscopic laryngeal surgery, Sistrunk procedures, tympanoplasties, a thyroidectomy, a parotidectomy, and various soft tissue excisions.
Having done some limited mission work in the past, the biggest surprise to me on this trip was the quality of the facility. In an area where the local residents had no clean water and inadequate plumbing and electricity, we were able to operate in a facility that met U.S. standards in these capacities. This was truly extraordinary. Because of the high quality of the hospital and, more important, the high character of the Honduran and American volunteers involved, I know we were able to impact the patients in a big way and will continue to do so on future trips. Our friendships with the missionaries and permanent volunteers at the hospital and nearby orphanages will allow us to accurately gauge our impact throughout the coming year and improve the effectiveness of the care we will provide in Honduras going forward.
In the big picture of international surgical mission work, there will never be two experiences that are the same, neither in the impact on the volunteer nor the impact on the patients. In many instances, the long-term effectiveness of a short-term experience is difficult to measure, making evaluation and validation of our work challenging. Furthermore, it is impossible to account for all variables in this type of setting. Things like safety, natural resources, medical equipment, and surgical
complications can change or arise in an unpredictable fashion, all of which can have an impact on patient care. However, I do believe there are aspects of this type of mission work that you can control. Strong leadership, high character, and loyalty to the cause and the patients are the most important of these and can overcome the inevitable challenges of short-term mission work.
Much thanks to Baptist Medical & Dental Mission International (BMDMI), our sponsoring organization, for hosting us during our week in Honduras and the AAO-HNSF Humanitarian Efforts Committee for graciously helping with funding. Q: When should I use an unlisted code?
A: An unlisted code should be used to report a procedure when no Category I or III CPT code exists to describe the procedure.
Q: When shouldn’t I use an unlisted code?
A: When a valid CPT code exists to describe the procedure. Unlisted codes should not be utilized as an attempt to obtain increased reimbursement in cases where a CPT code exists, but the reimbursement for the existing CPT code is low.
Q: Are there steps I should take to increase the likelihood that my unlisted code will be paid?
A: Yes, best practices for using unlisted codes include, but are not limited to, the following:
Obtain prior authorization or certification for elective cases.
Learn what the carrier needs to process the unlisted code; many request the following: Submit your claim on a CMS 1500 claim form with an operative note and cover letter outlining how you are using the unlisted code and how you’ve selected your “base code.” Access the Academy’s sample unlisted code cover letter here: http://www.entnet.org/Practice/Appeal-Template-letters.cfm
Select a base code that is SIMILAR to the procedure you performed. The code should represent surgery on the same area of the body and utilize a similar approach and exposure to the procedure you performed.
In your cover letter, list two to three things that make the unlisted procedure more or less difficult than the comparator CPT code.
List the RVUs of the similar code to be sure it reflects a fair value for the work you have performed. If it does not, select a different base code.
Use your normal fee for the comparison code. Note that the payer will then adjust this up or down from their fee schedule, not your charge.
Q: Are there any other areas to be cautious about, or to avoid?
A: Yes, keep the following in mind when using unlisted codes:
As is the case with all claims, do not unbundle procedures that are included in a global surgery.
Do not use modifier 22 on unlisted procedure codes.
Do not report more than one unlisted procedure code per operative session.
Payment delays are likely, as the payer may perform a more detailed review of your claim when an unlisted code is submitted.
Make certain your documentation is fully supportive of the service and clearly describes the work performed, especially if it “deserves” a significantly higher reimbursement than the base code.
For additional coding guidance and resources, visit the Academy’s coding corner at: http://bit.ly/ENTcoding Q: I’ve noticed that there are not any coding edits in place for CPT 31000 Lavage by cannulation; maxillary sinus (antrum puncture or natural ostium) when billed with 31295 (endoscopic balloon dilation of the maxillary sinus). Does this mean I can code separately for the work of lavage when performing this service?
A: No. The lavage is a lower-valued procedure performed at the same operative session on the same structure (maxillary sinus) and, therefore, would be included in the primary procedure code of 31295. Some additional things to consider are:
The vignette associated with 31295 includes a statement that a catheter for irrigation may be placed at the same time. This unequivocally means that irrigation of the dilated sinus INCLUDES irrigation if performed at the same session.
The only time 31000 should be reported with 31295 is if the primary procedure is performed on one side and ONLY an irrigation is performed on the opposite, contralateral side. In this case, the procedures would be reported using RT and LT modifiers. A -59 modifier would not be used, as there is not currently a CCI edit in place for this code combination.
31000 is an open code [i.e., anterior rhinoscopic guided service] and 31295 is an endoscopic code.
31000 represents a separate procedure in which the nose is anesthetized, decongested and a needle or cannula inserted into the antrum for irrigation. It is not intended for flushing through a patent or newly created surgical opening into the antrum.
The same logic would apply to 31002 with relevant sphenoid codes.
Q: In addition, there is a CCI edit in place of “1” for the code combinations of 31000 with 31256 (endoscopic maxillary antrostomy) and 31267 (endoscopic maxillary antrostomy with tissue removal from within the sinus), but I am able to bypass the edit using modifier 59 (distinct procedural service). Is it appropriate to append modifier 59 to 31000 in these instances?
A: No, it is not appropriate to append modifier 59 to 31000 just to get the procedure paid. You must meet the criteria for use of modifier 59 in order to use the modifier appropriately and bypass the CCI edits. The lavage is a lower-valued procedure performed at the same operative session on the same structure (maxillary sinus) and, therefore, would be included in the primary procedure codes of 31256, 31267. Some additional things to consider are:
The only time 31000 should be reported with 31256, 31267 with a 59 modifier is if the primary procedure is performed on one side and ONLY an irrigation is performed on the opposite, contralateral side.
31000 is an open code [i.e., anterior rhinoscopic guided service] and 31256, 31267 are all endoscopic codes.
31000 represents a separate procedure in which the nose is anesthetized, decongested and a needle or cannula inserted into the antrum for irrigation. It is not intended for flushing through a patent or newly created surgical opening into the antrum.
Overuse of the -59 modifier with certain code combinations can trigger a CMS review of the code combination that could alter our ability to bill separately for these codes in the future.
The same logic would apply to 31002 with relevant sphenoid codes. With multiple events this summer during the August Congressional recess, the AAO-HNS In-district Grassroots Outreach (I-GO) program had a successful kickoff. As with many new programs, there were a few logistical issues to overcome, including the surprisingly limited number of events hosted by Members of Congress during the August break due to concerns about being “attacked” for their policy positions while attending public events.
However, AAO-HNS members met and overcame these challenges. Several members hosted private practice visits for their Members of Congress, providing tours of their facilities, demonstrating the tools of the trade, and introducing them to the hard-working staff that are essential to running a successful practice. Members without private practices coordinated calendars with their representatives and met locally with them at their legislators’ district offices. This provided a more personal and less threatening setting for the legislators to speak with physicians on the front lines of patient care.
Regardless of the venue, these visits provided Members of Congress with a firsthand account of AAO-HNS legislative priorities, including the repeal of the Sustainable Growth Rate payment formula, truth-in-advertising initiatives, and support for Graduate Medical Education funding.
If you are interested in representing the specialty in a home district visit with your local policymakers, visit www.entnet.org/advocacy or contact govtaffairs@entnet.org. During the AAO-HNSF 2013 Annual Meeting & OTO EXPOSM in Vancouver, BC, Academy members visited the ENT PAC and Grassroots Booth—the Government Affairs “hub” during the meeting—to learn more regarding the Academy’s federal legislative priorities, grassroots initiatives, and new/ongoing political programs. Here is a brief overview of what took place in Vancouver.
#FixtheSGR
This year, the U.S. House Energy and Commerce (E & C) and Ways and Means (W & M) committees have been diligently working on the development of legislation to repeal the flawed Sustainable Growth Rate (SGR) formula used to determined payments to physicians in the Medicare program, and replace it with a new payment system that rewards the delivery of high-quality and efficient healthcare. In late July, legislation was unanimously passed by the E & C Committee, setting the stage for possible passage of legislation by the end of the year. AAO-HNS members are encouraged to contact their lawmakers via an AAO-HNS “Legislative Action Alert” to urge swift passage of SGR repeal legislation. In Vancouver, the Grassroots Table provided attendees with easy access to the Action Alert and additional information about other AAO-HNS federal legislative priorities.
Calling All Residents!
In Vancouver, the ENT PAC Board of Advisors and staff were excited to launch a new Resident and Fellows-in-Training PAC and Advocacy Involvement Campaign. The program, which relies on a simple point system, provides participants the opportunity to accrue points for themselves and their training program based on involvement in various AAO-HNS advocacy and political activities. For more information, email govtaffairs@entnet.org.
ENT PAC Goes “Rogue”
On Monday, September 30, all 2013, ENT PAC Investors were invited to attend the annual PAC “thank you” reception. This year’s event took place at the Rogue Kitchen & Wetbar in Vancouver. The ENT PAC Board of Advisors and staff thank all 2013 PAC Investors! For more information, contact entpac@entnet.org.*
Lunch among Leaders
On Tuesday, October 1, former Member of Parliament and Leader of the Liberal Party in Canada, the Honourable Bob Rae, spoke at the ENT PAC Chairman’s Club ($1,000+ annual contribution) Luncheon. The lunch featured a roundtable discussion about healthcare delivery in the U.S. and Canada. For more information about ENT PAC Leadership Clubs, visit www.entpac.org.
What Is I-GO?
The newest AAO-HNS advocacy program, the In-district Grassroots Outreach or “I-GO” program, was launched earlier this year and extensively discussed during this year’s annual meeting. The program, which encourages AAO-HNS members to engage in in-district advocacy opportunities (e.g., meeting with a lawmaker, attending a fundraiser, participating in a townhall, etc.), was a main tenet of the Government Affairs programming in Vancouver. The AAO-HNS Government Affairs staff and physician advocacy leaders hope the I-GO program will strengthen our advocacy “footprint” and provide AAO-HNS members with increased opportunities to develop relationships with lawmakers locally and, when applicable, participate in the political process. For more information, contact govtaffairs@entnet.org.
Until the AAO-HNSF 2014 Annual Meeting & OTO EXPOSM in Orlando, ensure you receive the latest legislative and political news by joining our social media networks. “Follow” us on Twitter @AAOHNSGovtAffrs, “Like” us on Facebook, and “Connect” to us on LinkedIn!
*Contributions to ENT PAC are not deductible as charitable contributions for federal income tax purposes. Contributions are voluntary, and all members of the American Academy of Otolaryngology—Head and Neck Surgery have the right to refuse to contribute without reprisal. Federal law prohibits ENT PAC from accepting contributions from foreign nationals. By law, if your contributions are made using a personal check or credit card, ENT PAC may use your contribution only to support candidates in federal elections. All corporate contributions to ENT PAC will be used for educational and administrative fees of ENT PAC, and other activities permissible under federal law. Federal law requires ENT PAC to use its best efforts to collect and report the name, mailing address, occupation, and the name of the employer of individuals whose contributions exceed $200 in a calendar year. ENT PAC is a program of the AAO-HNS, which is exempt from federal income tax under section 501 (c) (6) of the Internal Revenue Code. Rahul K. Shah, MD, George Washington University School of Medicine, Children’s National Medical Center, Washington, DC.
A few years back, there was real concern whether the patient safety and quality improvement renaissance following the Institute of Medicine’s report in 1999 was real. In other words, were we moving the needle in actually reducing adverse events, near misses, and medical errors? This is a very basic, albeit profound question. Some experts had questioned if focusing tremendous attention on patient safety and quality improvement was taking limited resources away from other competing priorities.
Within the last few years there have been myriad studies actually demonstrating an improvement in outcomes and other concomitant patient safety/quality improvement metrics in varying practice settings. It is of course exciting to see the needle move and the tremendous efforts of providers, such as our Academy members, working to improve the quality of care for our patients.
How did the needle move? A trite answer is that there were so many opportunities that focusing on the low-hanging fruit was productive. Indeed, our Academy employed similar strategies when creating a prioritization matrix for patient safety and quality improvement work.
The bigger question is: What do we do now? How can we attack the larger problems and move the needle a similar magnitude? There are several large databases and quality improvement platforms, which I will refrain from naming, that are perhaps the wrong strategy (and I do not want to implicate any platform per se). Instead of macro-level snapshots of data, many of us believe that targeted, specialty-specific initiatives will be necessary to make an impact and go after the more elusive specialty-specific issues.
For example, Atul Gawande, MD, and his research team made incredible contributions to the understanding of the role of checklists, especially for surgery. The next iterations may be specialty-specific or case-specific checklists. Indeed, I know of many specialty practices, surgery centers, and hospitals that have such specialty/procedure-specific checklists to customize a standardized process.
The next generation of patient safety and quality improvement will undoubtedly require a tremendous amount of resources, as it will be geared toward specific groups of providers (emergency department physicians, hospitalists, psychiatrists, etc.). Furthermore, it will require a much broader group of leaders, as there will be hundreds of competing initiatives. An example is the Hospital Engagement Networks (HEN) that many of our hospitals participate in. These networks are essentially huge collaboratives in which hospitals get together to look at aggregate macro-level data, as well as best practices, to collectively improve the care in their own hospitals and for the HEN itself.
To my knowledge, there are no specific HEN metrics that are pertinent specifically to otolaryngology-head and neck surgery. I am aware of quality improvement collaboratives that are beginning in our specialty that are slowly gaining traction and will most certainly be highlighted in this column as they mature.
Nevertheless, the future of patient safety and quality improvement could not be more exciting. The prior decade has shown that the needle has moved and the future looks promising that the needle will continue to move. As expected, there will be different strategies and techniques that will be required to move the needle in this decade, but we are on the right track and there will certainly be more involvement among our specialty and our members.
We encourage members to write us with any topic of interest, and we will try to research and discuss the issue. Members’ names are published only after they have been contacted directly by Academy staff and have given consent to the use of their names. Please email the Academy at qualityimprovement@entnet.org to engage us in a patient safety and quality discussion that is pertinent to your practice. 
