Otolaryngology Coding Alert

Find out when it’s appropriate to report 31237 when performed post-surgically. 

Getting reimbursed properly for performing procedures is all in the details, especially in cases where the coding isn’t clear-cut. Don’t let denials and advice to steer clear of billing postoperative endoscopic debridement make you reluctant to submit legitimate claims. 

Gain the confidence to use 31237 (Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement (separate procedure)) by knowing what details to scour for in the medical record. And maximize the likelihood that a claim for post-op debridement receives its deserved reimbursement by gathering and submitting all the proper documentation and justification. 

To help you get started, we have compiled four tried-and-tested tips for maximizing your 31237 claims’ chances of success. 

Tip 1: See Which Surgery the ENT Initially Performed 

Otolaryngologists commonly perform functional endoscopic sinus surgery (FESS) to treat chronic sinusitis. In cases where the patient also needs work done on the nasal septum and/or inferior turbinates to improve breathing, ENTs often combine FESS with surgical interventions including: 

• Septoplasty 30520 (Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft) and/or 
• Turbinectomy 30130 (Excision inferior turbinate, partial or complete, any method), 30802 (Ablation, soft tissue of inferior turbinates… intramural (ie, submucosal), or 30801 (Ablation, soft tissue of inferior turbinates … superficial). 

ENTs may perform debridement (31237) after sinus surgery to address post-operative issues that may be causing discomfort and impairing the healing process such as crust, blood clots, and scarring. Before you can determine if you can report the debridement, you must identify the primary surgery. 

Why: The Medicare Physician Fee Schedule (MPFS) assigns different global periods to septoplasty, turbinectomy, and FESS codes. Codes 30520 and 30130 have a 90-day global period, while 30802/30801 have a 10-day global period. But FESS codes contain zero global days. “This means that the values assigned to FESS codes via their RVUs [Relative Value Units] are based on the surgeons being paid for all services as of the first post-operative day since there is no global period associated with FESS codes,” says Barbara J. Cobuzzi MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, CMCS, of Tinton Falls, New Jersey. “This valuation and assignment of zero global days were done by design in order to preserve relative values in the specialty of otolaryngology for other CPT^® codes for which the RVUs were needed. By making FESS CPT^® codes with a 0-day global, less RVUs were allocated to FESS surgeries, leaving more relative values for other CPT^® codes,” she adds. These different global periods equate to two coding and reimbursement scenarios. 

Scenario 1: FESS only – The ENT performs debridement after FESS without septoplasty or turbinectomy. Because FESS codes have zero global days, you can bill the medically necessary debridement after endoscopic sinus surgery with 31237. The chart needs to have appropriate documentation that the physician performed endoscopic sinus debridement and the debridement was the focus of the visit. Remember, 31237 is a unilateral code, so if the ENT debrides both sides, append modifier 50 (Bilateral procedure) to 31237. 

Do this: Challenge payers following Medicare’s resource-based relative value scale (RBRVS) for their fee schedule, but bundle the debridement as included in a payer-created FESS package. CMS assigned payment values for FESS assuming that medically necessary subsequent diagnostic endoscopies (31231 (Nasal endoscopy, diagnostic, unilateral or bilateral …)) or surgical endoscopies with debridement (31237) would be reimbursed separately as outside the 0-day global period. The physician’s documentation must include procedure details and demonstrate medical necessity in order to support any appeal. Also, check with your payers, as some will pre-certify post-op debridement. “It is not a bad idea to pre-certify these postoperative 31237 procedures with any payer that will pre-certify the service,” Cobuzzi notes. 

Scenario 2: Multiple procedures – When your ENT performs debridement within 90 days after FESS with septoplasty (30520) and/or inferior turbinate excision (30130) or within 10 days of radiofrequency coblation /vivaer reduction of the inferior turbinates (30802/30801), the debridement falls within the global period of the septoplasty and turbinectomy codes. Being able to bill the debridement hinges on the answer to another question, so you’ll need to dig a little deeper. 

Tip 2: Find Out Why the ENT Performed Debridement 

When the debridement occurs within 90 days of a major procedure or within 10 days of a minor procedure, you need to focus on what the otolaryngologist is debriding and why after performing a septoplasty and/or turbinectomy with FESS. 

In black and white: Remember, the sinuses are entirely different structures that are not contiguous with the nasal cavity. As such, sinus debridement is entirely unrelated to the work and postoperative care associated with septoplasty and inferior turbinate excision/reduction. So, payers will reimburse 31237 separately when performed as postoperative care following FESS procedures, which have a 0-day global period. 

Look through the documentation and verify: 

• the ENT performed sinus debridement; 
• the post-op debridement is related to the 0-day global FESS surgery; and 
• the reason for the debridement is unrelated to why the surgeon worked on the septum and/or inferior turbinates. 

When cases fit the above criteria and the documentation supports this, you can bill for the sinus debridement. The ENT surgeon must clearly document the above points so that you have the support to appeal any denials and show the payer that the debridement was related to the 0-day sinus procedure and not the 90-day or 10-day global procedures. But before adding 31237 to the claim, you’ll need to append a modifier. 

Tip 3: Reach for the Right Modifier 

Although you might be tempted to use modifier 58 (Staged or related procedure or service by the same physician … during the postoperative period), most coding experts agree that a better choice is to append modifier 79 (Unrelated procedure or service by the same physician … during the postoperative period) to 31237 to indicate that the debridement is unrelated to the reason that the ENT worked on the septum and/or turbinates, says Laura Carbonaro, past director of revenue cycle central billing operations with North Shore-LIJ Health System. Documentation should demonstrate the debridement is solely related to the sinuses and it should show the medical necessity for the sinus debridement. 

“If you don’t attach the 79 modifier, the payers’ claims adjudication software will most likely reject the debridement as inclusive,” Carbonaro says. “If there are other modifiers on the debridement, make sure the 79 is in the first position so your claim doesn’t get summarily denied against an unrelated global. Also, be certain that the diagnosis codes used for the debridement are related to the FESS.” 

Coding note: Remember 31237, unlike 31231, is a unilateral code, so if the ENT performs the debridement on both sides, append modifier 50 (Bilateral procedure) to 31237

. 

Tip 4: Know Which Diagnoses Support Post-Op Sinus Debridement 

When your otolaryngologist performs a post-op sinus endoscopy with debridement, many diagnoses related to recurrent or chronic sinus conditions can help justify the procedure, including: 

• J01.11 (Acute recurrent frontal sinusitis) 
• J01.31 (Acute recurrent sphenoidal sinusitis) 
• J32.2 (Chronic ethmoidal sinusitis) 
• J34.89 (Other specified disorders of nose and nasal sinuses) 

Keep in mind, this is not an all-inclusive list. As with any diagnosis, having more details in your physician’s documentation is the first step to selecting the most accurate codes supporting their services.