Otolaryngology Coding Alert

Question: Our otolaryngologist performed a balloon procedure in an ASC. I billed 31276, but the payer denied our claim because the facility billed 31296. We were paid based on 31296, which is a huge difference in reimbursement. Any ideas on how (or if) we should appeal? 

California Subscriber 

Answer: Start by checking the surgeon’s documentation. If he noted that he removed tissue from the sinus, the correct code is 31276 (Nasal/sinus endoscopy, surgical with frontal sinus exploration, with or without removal of tissue from frontal sinus). 

Sometimes coders see “balloon sinus dilation” in the documentation and automatically report a code from 31295-31296. In your case, 31296 (Nasal/sinus endoscopy, surgical; with dilation of frontal sinus ostium [e.g., balloon dilation]) is incorrect if the surgery involved tissue removal. You’ll need to educate the ASC staff to recode the procedure and then appeal your denial. 

Take note: As a result of the facility’s incorrect coding, you’ll have to appeal the denial with a copy of the operative note, pointing out the removal of the tissue. You might want to include a copy of the policy from the AAO/HNS web site where they indicate that the traditional FESS codes must be used in balloon cases when tissue is removed.