REIMBURSEMENT UPDATE: Cure Your Sinus Surgery Coding Woes With Clinical Details

Clearer documentation secures payment for oft-denied 31237

If you're having difficulty getting your nasal endoscopy claims paid, knowing the location of the procedure, the reason for it, and what to look for in the chart will boost your chances at earning proper reimbursement.
Don't Unbundle Diagnostic Endoscopies
Nasal endoscopies can be diagnostic or surgical. Diagnostic endoscopies allow the physician to detect abnormalities in the middle and inferior turbinates, such as polyps, neoplasms, and adhesions, says Bradley Chastant, MD, FACS, with Acadian ENT & Facial Plastic Surgery in Lafayette, La., who presented on sinus endoscopies at a recent American Health Information Management Association (AHIMA) meeting.
When coding sinus procedures, the first thing you need to find out is whether the service was solely diagnostic or whether the physician also performed a surgery, says George Alex, CPC, ACS-OR, managing partner of Iatro, a consulting firm in Baltimore. "If it's diagnostic only, the next questions will be, 'What areas were examined?' and 'Was it the nasal cavity alone, or was the physician accessing the nasal sinuses?' "
If the physician performed a diagnostic procedure along with a surgical one, you can't report them separately, Alex says - that's unbundling. When surgery is involved, diagnostic service codes 31231 (Nasal endoscopy, diagnostic, unilateral or bilateral [separate procedure]), 31233 (Nasal/sinus endoscopy, diagnostic with maxillary sinusoscopy [via inferior meatus or canine fossa puncture]), or 31235 (...with sphenoid sinusoscopy [via puncture of sphenoidal face or cannulation of ostium]) are included in the code for the surgical procedure and "it would be inappropriate" to bill them, Alex says.
Pinpoint Exact Area for Surgical Codes
Layer 1: Once you determine a procedure was surgical, you need to know which part of the sinuses the physician accessed. For example, if the doctor confined the scope to the nasal cavity, you may report 31237 (Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement [separate procedure]). But if she accesses other sinuses, such as the sphenoid or maxillary areas, you may need to use 31287   (... with sphenoidotomy) or 31256  (... with maxillary antrostomy).
Layer 2: If the physician removes tissue, you'll report a more specific code that describes both the area accessed and the tissue removal, and possibly the area of tissue removal. For instance, if the doctor performed an ethmoidectomy, you  need to know not only that the ethmoid sinuses were involved but whether anterior or both anterior and posterior cells were removed, Alex says.
Depending on which part the physician removed, you should report either 31254 (... with ethmoidectomy, partial [anterior]) or 31255 (... with ethmoidectomy, total [anterior and posterior]).
Tip: When the physician performs multiple procedures through the scope involving different areas, [...]

- Published on 2004-10-11