Otolaryngology Coding Alert

Your solo dilation coding will get easier come 2011.

With no dedicated code for a balloon sinuplasty, you're not alone if you've wondered how to code endoscopic sinus surgery involving the newer tool.

You, however, can confidently navigate to the right code or combo code. Focus on whether your otolaryngologist uses a balloon catheter for dilation alone or as part of a functional endoscopic sinus surgery (FESS). Don't overlook what your operative report should include and when you can code for multiple sinus procedures.

1: For Dilation Only, Go With Unlisted Procedure Code

To code for a balloon sinuplasty, focus on what the otolaryngologist is using the balloon for.

If the balloon is used to dilate the sinuses only, report unlisted code 31299 (Unlisted procedure, accessory sinuses), advises Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CENTC, CHCC, president of New Jersey-based CRN Healthcare Solutions. On the other hand, if the procedure involves more than just dilation, such as opening of the ostia, a traditional endoscopic procedure, select an appropriate FESS code. "The key is to find out if the balloon was used for only dilation," Cobuzzi says.

If the otolaryngologist uses only a balloon catheter to dilate either the maxillary,frontal, or sphenoid sinuses, the correct code is 31299, confirms Michael Setzen, MD, a practicing otolaryngologist in Great Neck, N.Y. and clinical associate professor of otolaryngology at New York University School of Medicine. Do not use a specific FESS code in addition to the unlisted FESS code 31299.

2011 update: Look for new CPT codes for dilation of the maxillary, sphenoid, and frontal sinuses in 2011, says Setzen, which may eliminate the need for reporting 31299 for balloon sinuplasties.

AAO-HNS policy: Code 31299 is the correct coding for the balloon sinuplasty dilation service "until the new codes are introduced in 2011, and apply to dilation of the frontal, maxillary, and/or sphenoid sinus. Balloon dilation of the maxillary ostium performed via the canine fossa approach is also reported with 31299, including cases in which tissue is removed from within the antrum," states the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) in a March release.

Careful: Don't treat 31299 as a bilateral code; report it only once, even if the otolaryngologist entered more than one sinus, Setzen adds.

You must explain to the payer why you are using the unlisted procedure code and detail what the procedure included, counsels Setzen. Do this either during pre-certifi cation or by attaching a letter of explanation to the operative note. Detail the sinuses the otolaryngologist entered -- for example, "The otolaryngologist entered the maxillary sinus on the left and the frontal sinus on the right, using dilation technology," suggests Setzen.

If the dilation was performed bilaterally, indicate this as well in the cover letter for the unlisted procedure code. Many times payers do not reimburse unlisted procedure codes properly during the first submission; you may have to send in the letter again to appeal for proper payment.

Tip: Give a comparative fee to an existing code to assist the payer in assigning a fee to the unlisted procedure code.

2: Use Single FESS Code for Traditional Instrumentation

If the otolaryngologist uses a balloon for dilation but continues with more work, don't opt for 31299.

Key: Look at whether the otolaryngologist uses the balloon only in the initial part of the surgical procedure, and then continues with more work on a specific sinus, says Setzen.

Example 1: If the otolaryngologist first introduces a balloon to enlarge the nasofrontal recess, and then performs more work to further enlarge and explore the nasofrontal recess, using a debrider or curette to improve drainage, you may use 31276 (Nasal/sinus endoscopy, surgical with frontal sinus exploration, with or without removal of tissue from frontal sinus).

"In [the above] instance, the balloon is used as an adjunct to traditional instrumentation. When the result is a frontal sinusotomy and tissue has been removed, the appropriate code is 31276 and the dilation is not separately reported," states the AAO-HNS release.

Example 2: If the balloon dilates the maxillary sinus, and then the otolaryngologist uses a microdebrider or other tool to enlarge the sinus further, lay 31299 aside and opt for a code such as 31256 (Nasal/sinus endoscopy, surgical, with maxillary antrostomy), offers Setzen.

Example 3: Alternatively, if the otolaryngologist removes a cyst after performing a balloon dilation of the  maxillary ostium and maxillary antrostomy, the ultimate code is 31267 (Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus).

Watch out: Don't fall into the trap of coding the above procedures as a "hybrid" surgery, reporting both the balloon sinuplasty and the endoscopic component, warns Setzen. Stick with one FESS code -- unless the otolaryngologist is performing a balloon dilation only (only 31299), or if the procedure is coupled with an ethmoidectomy (31299 + 31254/31255).

3: Separately Report Ethmoidectomy

If the patient requires an ethmoidectomy, don't miss this coding opportunity.

Code this: If the otolaryngologist performs a partial ethmoidectomy on the left side, for instance, and then uses a balloon catheter to dilate the maxillary sinus on the right, says Setzen, you would code the encounter as:

• 31254 -- Nasal/sinus endoscopy, surgical; with ethmoidectomy, partial [anterior] for the ethmoidectomy

• 31299 for the maxillary dilation.

Don't miss: Be sure to add 31254 (or 31255, ...total [anterior and posterior]) with 31299 on the ethmoidectomy claim, since 31299 "does not apply to endoscopic surgery of the ethmoid sinus as there is no current balloon technology for use in the ethmoid sinus," states the AAO-HNS release.

The above coding combo rings true regardless of whether the otolaryngologist performs the ethmoidectomy and additional sinus dilation on opposite sides or on the same side, points out Setzen.If the procedure requires the dilation of multiple sinuses, in addition to the ethmoidectomy, you still would code 31299 (only one time) in addition to 31254, Setzen says.

Explain in the op report which sinuses the otolaryngologist dilated with the balloon (such as the frontal and sphenoid) and that you are reporting this dilation with only one code -- 31299, he adds. Ensure the op notes are quite detailed, so the payer understands exactly what occurred during the procedures, and provide a reference for setting the dilation fee.

Help: If members continue to have problems with respect to coding and reimbursement for these procedures, please contact the AAO-HNS's Health Policy Department at healthpolicy@entnet.org.

Resource: Review the full AAO-HNS release at http://www.entnet.org/Practice/Coding-for-Balloon-Sinus-Dilation-2010.cfm.