Coding and Reimbursement for Endoscopic Endonasal Surgery of the Skull Base
06 February 2019 (online)
The American Medical Association's (AMA) Current Procedural Terminology (CPT) codes provide the national standard for reporting medical services and procedures performed by physicians. As such, these codes must be used to report services to third party payers and are the basis for reimbursement. Unfortunately, the codes do not always sufficiently describe the procedure, or may not even exist for the procedure, performed.
Endoscopic endonasal surgery of the skull base (EESSB) is now well established as an alternate surgical technique/approach for the treatment of skull base pathology but is not universally practiced at all institutions that perform skull base surgery. As a result, CPT codes do not exist for most EESSB procedures. Typically, EESSB is performed jointly by the otolaryngologist-head and neck surgeon (ENT) and neurosurgeon (NS). Therefore, coding can be complicated and third-party payers are often not familiar with the services provided, and reimbursement issues such as delayed or reduced payments result.
As the number of trained surgeons continues to expand, there is diversity of opinion and practice regarding optimal CPT coding. There is a recognized knowledge gap regarding current coding options for EESSB.
The purpose of this white paper is to provide surgeons, coders, billers, and third party payers a comprehensive understanding of current coding and reimbursement implications for EESSB procedures. Payer medical directors and associated professionals will find this paper a valuable source of information about EESSB to facilitate medical policy development and appropriate adjudication and payment of claims. This white paper is a collaboration of KarenZupko & Associates, Inc. (KZA) and the North American Skull Base Society, with representation from NS and ENT. As such, it provides guidelines for coding but is not intended to represent the official recommendations of physician specialty societies, governmental regulatory agencies, insurance providers, or healthcare consultants. Areas of controversy are noted with acknowledgement of divergent opinions. The NASBS and KZA assume no liability for any fraudulent claims or penalties resulting from coding practices as represented here.