Otolaryngology Coding Alert

Functional endoscopic sinus surgery (FESS) is a relatively common otolaryngological procedure that can be performed under a variety of circumstances, thus presenting otolaryngologists and their staff with special coding challenges.
 
The most commonly performed FESS procedures include:

31237 Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement (separate procedure)

31238with control of nasal hemorrhage

31254 Nasal/sinus endoscopy, surgical; with ethmoidectomy, partial (anterior)

31255 with ethmoidectomy, total (anterior and posterior)

31256 Nasal/sinus endoscopy, surgical, with maxillary antrostomy

31267 with removal of tissue from maxillary sinus

31276 Nasal/sinus endoscopy, surgical with frontal sinus exploration, with or without removal of tissue from frontal sinus

31287 Nasal/sinus endoscopy, surgical, with sphenoidotomy

31288 with removal of tissue from the sphenoid sinus.

Codes 31237 (Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement [separate procedure]) and 31238 ( ... with control of nasal hemorrhage) are set apart from the other procedures listed above in that biopsy, debridement, polyp removal (for 31237) and control of bleeding (for 31238) do not specify a particular sinus. Either procedure can be performed in the operating room or in the otolaryngologist's office.
 
Code 31237 is a separate procedure, which means it should not be billed when performed at the same time as more extensive sinus surgery. Code 31238 is reported when the otolaryngologist uses the endoscope not only to guide the packing process but also to control the bleeding.

1. If FESS is performed on the same day as a diagnostic endoscopy, bill for the FESS procedure only. A diagnostic endoscopy typically 31231 (Nasal endoscopy, diagnostic, unilateral or bilateral [separate procedure]) often precedes any of the FESS procedures above. None of the three diagnostic endoscopy codes 31231, 31233 (Nasal/sinus endoscopy, diagnostic with maxillary sinusoscopy [via inferior meatus or canine fossa puncture]) or 31235 (Nasal/sinus endoscopy, diagnostic with sphenoid sinusoscopy [via puncture of sphenoidal face or cannulation of ostium]) may be billed if FESS is performed on the same day, even if the diagnostic endoscopy led to the decision to perform the more extensive procedure. For example, if the otolaryngologist performs a diagnostic endoscopy with maxillary sinusoscopy (31233) that determines the need for a maxillary antrostomy (31256, Nasal/sinus endoscopy, surgical, with maxillary antrostomy), the otolaryngologist may perform the surgery then and there so that the patient does not have to make a second trip. However, only 31256 may be billed.

2. Use modifier -50 if the same procedure was performed on the right and left sinuses. Otolaryngologists probably perform more sinus services on both sides than on one side alone. However, because the basic diagnostic endoscopy code (31231) includes the words unilateral or bilateral"" in its descriptor" some coders believe that all sinus surgery includes both sides and that modifier -50 (Bilateral procedure) should not be used with an FESS code. This is not the case says Ann Hughes CPC coding specialist with Mid-Vermont Ear Nose and Throat in Rutland Vt. "31231 is the only code that cannot be billed bilaterally when performed on both sides " she says. "Even the two other diagnostic endoscopies 31233 and 31235 may be billed for both sides when appropriate."
 
Even if different FESS procedures were performed on each side but subsequently both sides require debridement during the same session modifier -50 may be appended to 31237 Hughes adds.
 
Note: Bilateral procedures are typically reimbursed at 150 percent of the rate of the unilateral procedure.

3. Billing for any follow-up procedures. Because all of the FESS procedures listed above have zero global days any follow-up procedures (such as debridements and E/M services) are supposed to be payable separately. Some private payers however reject claims for postoperative service stating that it fell within the global period even though Medicare indicates the global period for these procedures ends the day after the procedure is performed.
 
"When private carriers deny follow-up services after FESS procedures they are saying that charging for post-op care is unbundling. That is not actually the case " stresses 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. Cobuzzi notes that some carriers cite CPT guidelines stating that "uncomplicated follow-up care" is included in the surgical package even though CPT does not dictate the length of global periods.
 
Medicare includes only routine care that is provided on the same day as the surgery. In particular she says debridements and subsequent diagnostic endoscopies should be reimbursed separately because they are medically necessary. Cobuzzi adds that when the Relative Value Update Committee (RVUC) valued FESS procedures it assumed that other services would be reimbursed separately and that these procedures have zero global days.
 
"Private carriers can't have it both ways " Cobuzzi says. "If they want to use Medicare's fee schedule they can't retain relative value units but lose the zero-day global period."
 
Continued denials should be met with appeals letters to the state insurance commissioner and if necessary dropping the payer once the contract expires.

4. If different procedures are performed on the same sinus on different sides use modifier -59 on the lesser procedure. The otolaryngologist may perform a partial ethmoidectomy (31254 Nasal/sinus endoscopy surgical; with ethmoidectomy partial [anterior]) on the right side and a total ethmoidectomy (31255 ... with ethmoidectomy total [anterior and posterior]) on the left side. Both procedures may be reported in this case with modifier -59 (Distinct procedural service) appended to the partial ethmoidectomy: 31254-59 and 31255.
 
Note: Some carriers may prefer that modifiers -LT (Left side) and -RT (Right side) be appended to the respective procedures.

5. When surgery is performed on the maxillary or sphenoid sinuses determine if tissue was removed. Codes 31256 31267 (Nasal/sinus endoscopy surgical with removal of tissue from maxillary sinus) 31287 (Nasal/sinus endoscopy surgical with sphenoidectomy) and 31288 ( ... with removal of tissue from the sphenoid sinus) describe maxillary and sphenoid sinus procedures with or without tissue removal. If the otolaryngologist performs a maxillary antrostomy (31256) or sphenoidectomy (31287) and removes tissue on the same day only the tissue-removal code linked to the respective procedure (31267 or 31288) should be reported Hughes says.
 
On the other hand if the otolaryngologist performs sphenoidotomy on one side and sphenoidotomy with tissue removal on the other the code including tissue removal should be listed first and the lesser-valued procedure should be appended with modifier -59 she says.
 
Again some carriers may prefer modifiers -LT or -RT to be used. The tissue removal should be clearly documented in the procedure notes otherwise it may be difficult to justify it Hughes adds.
 
Note: Neither the partial nor the complete ethmoidectomy codes refer to removal of tissue. Meanwhile 31276 (Nasal/sinus endoscopy surgical with frontal sinus exploration with or without removal of tissue from frontal sinus) which is used to report frontal sinus endoscopy is used "with or without removal of tissue."
 
 
6. Image guidance. In complex FESS surgeries stereotactic guidance may be used to assist the otolaryngologist. In such cases the service is reported separately with 61795 (Stereotactic computer assisted volumetric [navigational] procedure intracranial extracranial or spinal [list separately in addition to code for primary procedure]).
 
As an add-on code 61795 is not subject to multiple-surgery reductions and should be billed at full fee Cobuzzi says.
 
However she cautions that otolaryngologists should only report the use of these devices in difficult cases and only when the Findings Section in the operative report refers to a particular problem such as an altered surgical field massive polyposis or isolated sphenoid sinus surgery.
 
The use of image guidance should be dictated in the operative report Cobuzzi adds.

7. Documentation. The otolaryngologist may perform an extensive procedure but document what he or she did in a cursory way.
 
If for example the procedure notes merely state "Patient came in; post-status excision; we did bilateral endoscopic nasal debridement" and there are no findings or indications the 31237 claim may be invalidated in an audit.