Otolaryngology Coding Alert

Not sure if you should use 31233 and/or 31235 when the patient already has windows? Stick with 31231.

Experts have recommended that otolaryngologists could report maxillary or sphenoid sinusoscopy without performing the puncture at the same session. But a recent bulletin from the American Academy of Otolaryngology -- Head and Neck Surgery (AAO-HNS) puts an end to that option.

After numerous inquiries on the requirements of 31233 (Nasal/sinus endoscopy, diagnostic with maxillary sinusoscopy [via inferior meatus or canine fossa puncture]) and 31235 (Nasal/sinus endoscopy, diagnostic with sphenoid sinusoscopy [via puncture of sphenoidal face or cannulation of ostium]), the AAO-HNS gave definitive answers on these codes- requirements. Here's what you need to grasp.

Coders and associations alike pointed to the inclusion of "or" in CPT's 31233 descriptor to support the now-outdated rationale that you could use sinusoscopy code 31233 without performing a puncture. Code 31233 "describes the same procedure accomplished by two distinct techniques: via inferior meatus OR canine fossa," says the American Association of Ambulatory Surgery Centers (AAASC) in a January 2005 letter to CMS.

Technique 1 was: "In the former instance, the surgeon explores the sinus by threading an endoscope through the nasal passages. This is a relatively painless procedure that is easily furnished in the office setting," according to the AAASC letter.

Technique 2, now the only appropriate method, according to the AAO-HNS, is: The latter technique, however, involves exploring the sinus by jamming a trocar through the roof of the patient's mouth, and inserting an endoscope through the new cavity. This latter procedure is very painful and would almost never be performed without sedation, which can only be safely administered in a facility setting."

The key in selecting 31233 was that the otolaryngologist had to explore the maxillary. "Consultants reasoned that if the patient had windows from a prior surgery that allowed the surgeon access through the inferior meatus, otolaryngologists could consider this appropriate use of 31233," says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC, director of outreach programs for the American Academy of Professional Coders based in Salt Lake City.

You could previously have interpreted the "or" in 31235's parenthesis "via puncture of sphenoidal face or cannulation of ostium" to support coding a sphenoid sinusoscopy without puncture. But because patients are rarely open into the sphenoids and otolaryngologists do not often examine them in the office diagnostically, this rationale was not really debated or applicable. In addition, otolaryngologists infrequently use this code.

But an insurance carrier that disallowed 31233 in the office caused one coder to question the dual-technique interpretation. Code 31233 describes a trocar puncture that the surgeon made either directly into the inferior meatus area of the nose or after a mucosal incision into the canine fossa of the maxilla, says Ginny McManus, billing manager at BergerHenry ENT Specialty Group in Pennsylvania. "I interpret [CPT's description] to mean the puncture is done at the same session as the scope."

And it turns out McManus is right. "CPT codes 31233 and 31235 require a puncture or trocar cannulation prior to placing the scope into the sinus," states the AAO-HNS in its recently released FAQ "Reporting Nasal/Sinus Endoscopy: CPT Codes 31233, 31235" (available at http://www.entlink.net/practice/faq/upload/31233%20and%2031235%20endoscopy.pdf).

New way: When an otolaryngologist performs an endoscopic exam after a maxillectomy's or sphenoidectomy's (open procedures) postoperative global period (90 days) to view the interior of maxillary or sphenoid sinuses through existing surgically created patent sinusostomies, you should report the endoscopy with 31231 (Nasal endoscopy, diagnostic, unilateral or bilateral [separate procedure]), not 31233 and/or 31235, according to the Academy.

"The use of 31233 or 31235 to report diagnostic sinus endoscopy performed via an existing and patent opening into the maxillary or sphenoid sinus represents incorrect CPT coding," the AAO FAQ says.

Restricting 31233 to a maxillary sinusoscopy involving same-session puncture supports the code's work relative value unit (RVU). Commenters who reviewed procedures for the ASC approved list said that 31233 "describes a number of different procedures, some of which are significantly more complex than others reported using the same CPT code," reported CMS in the "Medicare Program; Update of Ambulatory Surgical Center List of Covered Procedures; Interim Final Rule" published on page 23697 of the May 4, 2005, Federal Register (http://a257.g.akamaitech.net/7/257/2422/01jan20051800/edocket.access.gpo.gov/2005/05-8875.htm).

Problem: Allowing the maxillary sinusoscopy to represent, as described by the AAASC, "a procedure that may be accomplished by either of two distinct approaches, one of which may require no anesthesia while the other (requiring insertion of a trocar through the roof of the patient's mouth) does require sedation in a facility setting," jeopardized the value of 31233. The puncture requirement now eliminates the work RVU inequity between the two approaches.

The Medicare Physician Fee Schedule assigns the same work RVU to a code, regardless of location. For 2007, 31233 has 2.18 work RVUs.