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News -> April, 2002 News
Jerry Schreibstein, MD FACS
Massachusetts Society of Otolaryngology, President-elect
Ever heard of an "S code"? Well I had not until our state Blue Cross Blue Shield carrier (BCBSMA) notified us that they were implementing S2343 to identify post-operative debridement following endoscopic sinus surgery. I asked myself, "Don't we already have a code to cover that service (31237)?" That's when I got a crash course in how the CPT system works.
It began in November 200, when the Massachusetts Society of Otolaryngology (MSO) attempted to get BCBSMA to reimburse our members for post-operative debridement (31237) following FESS combined with septoplasty. We were having no problems with reimbursement of 31237 in the post-operative period of 0-day global surgeries. However, BCBSMA refuses to pay for 31237 when FESS and septoplasty (90-day global procedure) performed on the same day. After several months of discussion, we were unable to convince them to cover this procedure despite using the arguments of unrelated sites of surgery, -79 modifiers, etc. We were still working on that problem, when they informed us they would be seeking a new CPT code for post-operative debridement. Thinking that BCBSMA through their national CPT representative would go through the usual channels ( AMA CPT, ARS and AAO-HNS) we didn't think much of their effort.
In August 2001, just prior to the ARS and Academy meetings, we were notified that there was a new S code to delineate post-operative debridement following FESS. I immediately contacted George Roman from the Practice Management Department at the AAO-HNS, and was put in touch with Richard Waguespack, Chair of the Carrier Relations Committee of the Board of Governors. I also contacted Joe Jacobs, the Socioeconomic Chair of the ARS. It was through the efforts of Mr. Roman that I discovered there are really 3 levels of CPT codes. Level I codes are those codes we are most familiar with to describe the E/M services and the procedures we perform. Level II and III codes fall under the Health Care Financing Administration's Common Procedure Coding System (HCPCS). Level II codes typical are used to identify products, supplies and services not included in the existing CPT codes. Level III S codes were local codes used by the insurance industry to identify procedures not included in level I. These codes, unlike level I codes, are developed by CMS (Formerly HCFA) and the insurance industry without organized medicines involvement.
In a letter to Thomas Scully, Administrator CMS, Dr Richard Holt, EVP of the AAO-HNS, pointed out that the adoption of level III S codes (local codes) as level II codes undermines the current CPT system and violates the intent of the Health Insurance Portability and Accountability Act (HIPPA). Unfortunately, HIPPA is not yet in effect. The inclusion of S codes also undermines the larger RBRVS system that established work values for CPT code 31237. No work values are assigned to S 2342, as this code was developed outside the RBRVS system. To my knowledge no formal action has been taken by CMS on this issue.
After Dr. Holt's letter, it became apparent that BCBSMA would implement this code in October 2001, regardless of our objection as a state society. The MSO was successful in delaying the implementation of this code until January 2002 and met with representatives of BCBSMA in early December 2001 to discuss the above issues. Peter Friedensohn (MSO President) and myself, along with representatives of the Massachusetts Medical Society met with BCBSMA. At this point, they claimed not to be trying to replace 31237, but rather identify a lesser degree of service that they felt many providers were actually performing. Poor documentation of the services rendered by providers clearly opened the door for their arguments. We took this at face value and tried to negotiate the best compromise we could. It was clear they were not going to eliminate the idea of implementing S2343.
The following is the compromise reached and published in the BCBSMA January/February 2002 ProviderFocus:
HCPCS code S 2343-
"Nasal endoscopy for post-operative debridement following functional sinus surgery, unilateral or bilateral."
This code would be used to report:
"The limited removal of secretions, crusts, or debris from the middle meatus or middle turbinate using suction, irrigation, or straight forceps, requiring topical anesthesia (i.e., debridement after functional endoscopic sinus surgery (FESS))"
CPT 31237-
"Nasal sinus endoscopy, surgical with biopsy, polypectomy or debridement (separate procedure)"
To report:
"The removal of crusts, debris or devitalized tissue from the ethmoid, maxillary, and frontal sinus cavities requiring topical or general anesthesia and instrumentation (i.e., debridement of the posterior ethmoid cavity, frontal recess or maxillary sinus)."
I suspect this will be attempted in other states and likely serve as a precursor to a new CPT code requested by the national BCBS Association.
The representatives from BCBSMA clarified that:
- S2342 would be for limited debridement unilateral or bilateral.
- CPT 31237 would remain unilateral (billable bilaterally when appropriate).
- If CPT 31237 performed unilaterally and S2342 performed on second side both can be billed accordingly. ( There would be the appropriate multiple procedure discount for the secondary procedure S2342).
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