2016 Coding and Billing Information

1 2016 Coding and Billing Information NON-FACILITY SETTING. (PHYSICIAN OFFICE - Place of Service 11). CPT Procedure Coding PROPEL and PROPEL mini are intended for use following ethmoid sinus surgery, and PROPEL mini is also intended for use following frontal sinus surgery. These surgical procedures are commonly reported with the codes listed below. The work associated with placement of a drug-eluting sinus implant is already included in the work RVU calculation for these codes;. therefore separate reporting of implant placement is not appropriate when performed with these procedures. Placement of a drug-eluting sinus implant is integral to these codes: CPT Description 31254 Nasal/sinus endoscopy, surgical; with ethmoidectomy, partial (anterior).

2 31255 Nasal/sinus endoscopy, surgical; with ethmoidectomy, total (anterior and posterior). 31276 Nasal/sinus endoscopy, surgical with frontal sinus exploration; with or without removal of tissue from frontal sinus Placement of PROPEL may also occur following procedures which do NOT include the work associated with implant placement. Separate reporting may therefore be appropriate when performed with these procedures. The following is an example: Placement of a drug-eluting sinus implant is NOT integral to these codes: CPT Description 31296 Nasal/sinus endoscopy, surgical; with dilation of frontal sinus ostium ( , balloon dilation). If separate reporting of the work associated with implant placement is appropriate, and the work is not integral to the primary procedure, code selection is determined by the sinus in which the implant(s) is/are placed.

3 Specifically, Effective January 1, 2016 , the following codes apply when a drug-eluting sinus implant is placed in the ethmoid sinus either: as a standalone procedure;. in conjunction with a procedure to perform biopsy, polypectomy or debridement CPT Description 0406T Nasal endoscopy, surgical, ethmoid sinus, placement of drug eluting implant 0407T Nasal endoscopy, surgical, ethmoid sinus, placement of drug eluting implant; with polypectomy, biopsy or debridement (Codes 0406T and 0407T cannot be reported in conjunction with the following procedures because the work of implant placement is already included in the RVU calculation: 31200, 31201, 31205, 31240, 31254, 31255, 31288, and 31290.)

4 Codes 0406T and 0407T cannot be reported in conjunction with 31231 and 31237 because they are mutually exclusive.). If a PROPEL mini implant is placed in the frontal sinus, the following code may apply: CPT Description 31299 Unlisted procedure, accessory sinuses MPM 00175 Rev. D Revised May 2016 . CPT copyright 2016 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. HCPCS Coding for PROPEL and PROPEL mini Whether the work of placing the implant is integral to the primary procedure or separately reportable, the implant itself must be reported separately with a HCPCS code. To facilitate claims processing and payment for PROPEL and PROPEL mini when used in the non-facility setting, providers may report the codes listed below.

5 HCPCS Description Payor S1090 Mometasone furoate sinus implant, 370 micrograms Most Commercial Payors J3490 Unclassified drugs Medicare Contractors and Some Commercial Payors*. *When using HCPCS J3490, payors may require providers to submit additional Information to describe the name of the drug, the dose, and the NDC number. NDC Description 10599-0000-01 PROPEL (Mometasone furoate sinus implant, 370 micrograms 10599-0001-01 PROPEL mini (Mometasone furoate sinus implant, 370 micrograms It is the provider's responsibility to determine appropriate CPT Coding for related procedures, including CCI edits which limit concurrent code reporting, and appropriate HCPCS code selection for PROPEL or PROPEL mini based on payor guidelines and contract terms, as well as the setting of care.))

6 As always, providers should check with the payor for appropriate Coding . *Note: The use of Category III codes ( 0406T and 0407T) and unlisted codes ( 31299) typically requires providers to submit additional documentation to describe the services provided and the medical necessity for that patient. Coverage and payment are determined on a case-by-case basis. Separate payment of PROPEL or PROPEL mini is subject to the provider's contractual payment arrangement. Providers should refer to the patient's specific health plan for coverage guidelines since coverage varies by payor. For more Information on Coding and Billing for PROPEL, please contact Intersect ENT at: 866-242-4638 or email: The Information provided is for the benefit of Intersect ENT customers and offers general coverage, Coding and payment Information for procedures associated with the use of PROPEL and PROPEL mini.

7 Users of this Information should understand that this is general Information , not legal guidance nor is it advice about how to code, complete, or submit any particular claim for payment. Information provided is not intended to increase or maximize reimbursement by any payor. The Information provided represents Intersect ENT's understanding of current reimbursement policies. The suggested codes are to be used only to facilitate appropriate Coding and should not be construed as recommended guidelines in the establishment of policy or practice. Intersect ENT makes no representations or warranties with respect to the Information and disclaims any implied guarantee or warranty of fitness for any particular purpose.

8 Intersect ENT will not be liable to any individual or entity for any losses or damages that may be incurred by the use of this Information . Furthermore, Intersect ENT specifically disclaims any liability or responsibility for the results or consequences of any actions taken in reliance on this Information . It is always the provider's responsibility to determine coverage and submit appropriate codes and charges for medically necessary services rendered, reported and appropriately documented. Providers should check and verify current policies and requirements with the payor for any particular patient. It is important to verify coverage for each patient as policies and guidelines can vary by payor and plan.

9 The key in all Coding and Billing to payors is to be truthful and not misleading and make full disclosures to the payor about how the product has been used and the procedures necessary to use the product when seeking reimbursement for any product or procedure. The PROPEL sinus implant is intended for use following ethmoid sinus surgery to maintain patency. PROPEL mini is intended for use following ethmoid or frontal sinus surgery to maintain patency. The implants are intended for use in patients 18 years of age. Contraindications include patients with intolerance to mometasone furoate (MF) or a hypersensitivity to bioabsorbable polymers. Safety and effectiveness of the implant in pregnant or nursing females has not been studied.

10 Risks may include pain/pressure, displacement of implant, and possible side effects of intranasal MF. The most common adverse events in clinical studies were sinusitis, headache, epistaxis and bronchitis. For complete prescribing Information see IFU at Rx only. 2016 Intersect ENT Inc. All rights reserved. INTERSECT and PROPEL are trademarks of Intersect ENT, Inc. MPM 00175 Rev. D Revised May 2016 . CPT copyright 2016 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.