Otolaryngology Coding Alert

With the advent of functional endoscopic sinus surgery (FESS), most sinus patients no longer require open procedures. But otolaryngologists still perform these if the FESS cannot be attempted or completed. Of the many open sinus procedures listed in CPT, perhaps the most frequently performed is a radical maxillary sinusotomy, known as Caldwell-Luc (C-L) for the American and French physicians who pioneered the procedure.
 
C-L codes are 31030 and CPT 31032 . The first procedure, which involves performing the antrotomy but not removing polyps, is rarely performed.
 
Unlike 31020, the other open maxillary antrotomy listed in CPT, the C-L antrotomy does not involve an intranasal approach to allow the sinus to drain. Instead, an intraoral incision is made above the upper gums to gain wide access, which may be required for certain types of masses.
 
A C-L antrotomy may be performed when the ENT can't get the job done endoscopically, notes Barbara Cobuzzi, MBA, CPC, CPC-H, an otolaryngology coding and reimbursement specialist and president of Cash Flow Solutions, a medical billing firm in Lakewood, N.J.
 
"Patients often require work on more than one sinus," Cobuzzi says. "The otolaryngologist may perform an endoscopic ethmoidectomy and then try to use the scope inside the maxillary sinus but cannot access all the polyps. In that case, an open C-L antrotomy may be required."
 
To correctly report this situation, Cobuzzi says, the C-L with removal of tissue (31032) and the appropriate FESS ethmoidectomy (either 31254 or 31255) may be billed separately.
 
Cobuzzi also notes that C-L with removal of tissue differs significantly from its FESS counterpart, 31267 (Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus).
 
For example, FESS procedures have zero global days, whereas open surgeries (such as C-L) have 90-day globals. This means that any subsequent services, such as follow-up visits or debridements, are included in the C-L procedure and should not be billed separately. These services are supposed to be payable separately when endoscopic sinus surgery is performed, but some private carriers impose their own global periods (15- or 45-day globals, for example) on FESS procedures.
 
Note: Open procedures reimburse at a higher rate because the 90-day global has been valued to include follow-up visits or other services related to the procedure and the procedures involve more risk to the patient (more bleeding and a larger wound).
 
Like surgical sinus endoscopy, C-L procedures are often performed on both sides. When this is the case, -50 (Bilateral procedure) should be appended to 31032, Cobuzzi says.

Sometimes a maxillary procedure is begun endoscopically, but the otolaryngologist has to convert to an open procedure. This may occur at any time during surgery, but regardless of how much time was spent endoscopically before the decision to convert to open was made, only 31032 should be billed, says Chrissy Rogan, CPC, billing coordinator with Metropolitan Ear, Nose and Throat, an otolaryngology practice in Alexandria, Va.
 
Medicare guidelines clearly state that when an endoscopic procedure is converted to open, only the open procedure is billed. Although CPT states that both procedures may be billed with -52 (Reduced services) appended to the endoscopic procedure that was not completed, most private payers follow Medicare's lead on this issue and will pay only for the open procedure.
 
Although it is performed more often than others, C-L and all other open procedures are no longer the norm. As a result, when an endoscopic maxillary antrostomy has to be converted to an open C-L, the operative report should clearly indicate why the endoscopic procedure was converted to open surgery, particularly since open surgery reimburses at a higher rate, Rogan says.
 
However, an endoscopic procedure performed on another sinus may be billed in addition to the open maxillary antrotomy. For example, a total ethmoidectomy is performed on both sides. The otolaryngologist uses the scope in the left and right maxillary sinuses but is unable to access all the polyps for removal. A C-L antrotomy is performed and, with the patient open, the remaining polyps are excised.
 
In this situation, the bilateral maxillary polypectomy would be reported first using 31032-50. The total ethmoidectomy could also be billed 31255-50. Payment for the ethmoidectomy will be reduced 50 percent as a multiple procedure.