Otolaryngology Coding Alert

Consider which coding method results in maximum reimbursement.

The functional endoscopic sinus surgery (FESS) changes from 2019 may feel like a distant memory at this point, but that doesn’t mean you’re immune from the occasional coding hang-up on a nuanced set of endoscopic services.

Today, you’re going to sharpen your FESS code reporting by breaking down a detailed set of procedures that will require you to utilize more than just your coding skillset to get right. That’s because the final coding verdict on nuanced FESS services often comes down to which set of codes yields the most reimbursement.

Test your FESS coding knowledge (and some arithmetic) by working your way through the following example.

Combine These Services Into Their Respective Codes

Code this: An operative note featuring a left total ethmoidectomy, a left sphenoidotomy, a left maxillary antrostomy with removal of tissue from the maxillary sinus, and a bilateral balloon sinuplasty with removal of tissue from the frontal sinus.

Disclaimer: Before considering codes to report, remember that you should not exclusively base your operative report coding on the procedure outlined in the report header. You must confirm the detail in the operative report aligns with the procedures detailed by the surgeon.

First, you want to address which FESS codes combine any of the procedures into a singular code. There is no mention of tissue removed from the sphenoid sinus, which leads you to conclude that the surgeon only opened the sphenoid sinus. Also, you will not report a balloon dilation code in the frontal sinuses since you’ve got documentation of the surgeon removing tissue from the frontal sinuses. Instead, a traditional endoscopic frontal sinusotomy is coded in place of the balloon dilation due to the removal of tissue. You’ll initially find that you’ve got one of two combination codes to choose from that involve an ethmoidectomy:

• 31253 (Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including frontal sinus exploration, with removal of tissue from frontal sinus, when performed)
• 31257 (Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including sphenoidotomy)

The sinus that is not combined with the total ethmoidectomy will be coded alone. That will be one of the following codes:

• 31276 (Nasal/sinus endoscopy, surgical, with frontal sinus exploration, including removal of tissue from frontal sinus, when performed)
• 31287 (Nasal/sinus endoscopy, surgical, with sphenoidotomy)

Consider Reimbursement on Your Way to Code Selection

Your next step in the equation is to have a look at the Medicare Physician Fee Schedule (MPFS) for each respective procedure in order to maximize reimbursement:

• 31253 — $519.69
• 31257 — $462.67
• 31276 — $391.93
• 31287 — $208.60

Before choosing codes, you’ve got to consider that the total ethmoidectomy, spehnoidectomy, and maxillary antrostomy with removal of tissue were only performed on the left side while the frontal sinusotomy was performed bilaterally.

Therefore, the combination codes, which include the total ethmoidectomy, can only be coded on the left side.

“You can code this surgery one of two ways,” says Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, of CRN Healthcare in Tinton Falls, New Jersey. “The first method will result in a Medicare reimbursement that’s $3.97 higher than the second method. However, keep in mind that the reimbursement from the various FESS code combinations that you may report are not always so closely aligned,” explains Cobuzzi.

Take a Few More Variables Into Consideration

Since the combination code in method one includes a frontal sinusotomy, you’ll append either modifier XS (Separate structure, a service that is distinct because it was performed on a separate organ/structure) or modifier 59 (Distinct procedural service) for payers who do not accept the X[ESPU] modifiers. Coding the second method, which pays a little less, does not require the separate procedure modifier since none of the CPT^® codes are bundled.

Consider: While in most instances you should opt for the higher paying reimbursement option, instances that result in a negligible difference between code combinations should leave you thinking more pragmatically about which method is less likely to experience any billing snags. The use of an overriding modifier such as XS or 59 will increase the likelihood that at the very least, you will need to submit the claim on paper in order to be reimbursed in a timely manner. It’s for this reason that you should instead consider which method is most convenient from a billing perspective when revenue between both methods is a relative wash.

In this example, however, $3.97 may be substantial enough to deal with the extra hassles of modifier 59 billing. “It’s also important to consider that over the course of a year, the $3.97 difference can add up and bring in additional income for the practice,” says Cobuzzi.