Otolaryngology Coding Alert

Tackle each portion of the service with a step-by-step approach.

The seemingly infinite ways you can combine functional endoscopic sinus surgery (FESS) codes can make your head spin before you even get a glimpse at the operative report. Couple that with the fact that there’s occasionally more than one way to code the same set of services correctly, and you’ve got yourself a classic case of coder overload.

That’s why it’s crucial to run through as many FESS scenarios as possible so you know what codes to report well in advance. Today, you’re going to work your way through a tricky case study that requires extra attention to detail to get right.

Get yourself better prepped for any FESS encounter by tackling this clinical scenario head-on.

Take Bundling, Modifiers, and More Into Consideration

Scenario: The otolaryngologist performs a bilateral frontal balloon sinus dilation and left sphenoid balloon sinus dilation, a bilateral maxillary sinus balloon dilation, a partial ethmoidectomy, and a partial submucous resection of the inferior turbinate.

The trickiest part of this set of FESS procedures is determining the coding for the bilateral frontal balloon sinus dilation and left sphenoid balloon sinus dilation. Even though the provider describes the frontal balloon sinus dilation as bilateral, the combination code requires the coder to strip the procedures down to what was performed on each side, so that the appropriate combination code is selected. The coding for both respective procedures is as follows:

• 31298 (Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); frontal and sphenoid sinus ostia)
• 31296 (Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); frontal sinus ostium)

There is an existing National Correct Coding Initiative (NCCI) edit bundling these two codes revealing a modifier indicator “1.” However, you should know that you may unbundle NCCI edits for procedures that are contralateral by simply appending modifiers LT (Left side) and RT (Right side) to the respective services. No additional modifiers, such as modifier 59 (Distinct procedural service) or XS (Separate structure, a service that is distinct because it was performed on a separate organ/ structure), are technically necessary when unbundling due to contralateral services.

Coder’s note: “While you may unbundle two distinct CPT^® codes using laterality modifiers, you should still append modifier 50 [Bilateral procedure] to 31298 and 31296 when performed bilaterally. Codes 31296 and 31298 have a bilateral surgery indicator of ‘1,’ meaning that they are eligible for modifier 50 reporting,” explains Ronda Tews, CPC, CHC, CCS-P, AAPC Fellow, director of billing and coding compliance at Modernizing Medicine in Boca Raton, Florida. Furthermore, “31296 and 31298 have medically unlikely edits [MUEs] of 1, which means that you should not report more than one unit of each respective code on a given date of service [DOS],” advises Tews.

Consider Payer Guidelines if Unbundling With Laterality Modifiers Doesn’t Work

Unfortunately, coding according to the guidelines doesn’t necessarily mean a given payer will appropriately unbundle both codes. There have been anecdotal reports among otolaryngology coders that the billing of these two services with contralateral modifiers still results in a denial of the column 2 code, 31296. There is some speculation that this could be based on internal payer guidelines restricting the reimbursement of two scope procedures that fall within the same family, also known as the “Multiple Scope Rule.” In this case, the “family” of codes includes any code that involves a sinus endoscopy with balloon dilation. It’s also worth noting that the “Multiple Scope Rule” typically applies to gastrointestinal endoscopic procedures.

However, what’s more likely is that the payer’s system doesn’t allow 31296 to be unbundled from 31298 using laterality modifiers. If you do receive a denial for 31296 when billing contralaterally, you should consider appending modifier XS or 59 as primary modifiers and the laterality modifiers as secondary modifiers to further emphasize to the payer that the two services should be unbundled. The coding should look as follows:

• 31298-RT
• 31296-XS (59)-LT

The next step in the coding process involves reporting code 31295 (Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); maxillary sinus ostium, transnasal or via canine fossa) with modifier 50 for the bilateral maxillary sinus balloon dilation. As you can see, this code also falls within the “family” of balloon dilation codes. But there aren’t many known reports of bundling denials due to the “Multiple Scope Rule” when pairing 31295 with 31298 or 31296.

While the concept of “access routes” is important for consideration in FESS procedure coding, you should not consider the ethmoidectomy as a necessary prerequisite to accessing the frontal sinus and sphenoid sinuses. Therefore, you will report 31254 (Nasal/sinus endoscopy, surgical with ethmoidectomy; partial (anterior)) as a separate service without any NCCI bundling considerations.

Your last service to consider is the submucous resection of the inferior turbinate, which you’ll report with 30140 (Submucous resection inferior turbinate, partial or complete, any method).