Otolaryngology Coding Alert

Question: Would you please clarify the use of 31233? Per CPT description, 31233 is -nasal/sinus endoscopy, diagnostic with maxillary sinusoscopy (via inferior meatus or canine fossa puncture)- and states a trocar puncture is made either directly into the inferior meatus area of the nose or after a mucosal incision into the canine fossa of the maxilla. I interpret this to mean the puncture is done at the same session as the scope. The November 2006 Otolaryngology Coding Alert states that 31233 can be done either by making a puncture or using windows that a physician previously created, and can be done in an office setting. You are also stating that modifier 52 (Reduced services) is not warranted. 

We were using this code up until last year, and we were attaching modifier 52 to it. But a large insurance carrier told us that this procedure could not be done in the office setting.

Pennsylvania Subscriber

Answer: Code 31233 can be done in the office setting. -- these procedures are often safely and appropriately furnished in a physician's office -,- states a letter from the American Association of Ambulatory Surgery Centers (AAASC) to CMS regarding additions and deletions of Medicare-approved ambulatory surgery center procedures. Certain variations of the procedure, however, may require facility services.

The AAASC in the letter then explains how 31233 can be done in either site depending on the method. -For example, procedure code 31233 describes the same procedure accomplished by two distinct techniques: via inferior meatus OR canine fossa. In the former instance, the surgeon explores the sinus by threading an endoscope through the nasal passages. This is a relatively painless procedure that is easily furnished in the office setting. The latter technique, however, involves exploring the sinus by jamming a trochar through the roof of the patient's mouth, and inserting an endoscope through the new cavity. This latter procedure is very painful, and would almost never be performed without sedation, which can only be safely administered in a facility setting.-

Implication: The puncture is one of the two methods that can be used to access the maxillary. But if the patient had windows from a prior surgery that allowed the surgeon access through the inferior meatus, this too can be considered an appropriate technique. The important thing is that the otolaryngologist must explore the maxillary.

Because 31233 can be done by either method, you do not need to attach modifier 52 to 31233 if the patient already has windows. The parenthetical phrase describes -or canine fossa puncture- not -and.- Therefore, there is no need to account for the easier access with a reduced- service modifier. The surgeon fulfills 31233's work if he explores the sinus cavity, regardless of technique. Answers to You Be [...]