Otolaryngology Coding Alert

Question: We just started doing a lot of 31292 (orbit compressions) and I have two claims that include FESS with that procedure. Both were filed with Humana with 31255, and both claims were denied even after appeal. I have checked and don’t see any edits. Is this correct?

Missouri Subscriber

Answer: Correct Coding Initiative (CCI) edits state that 31255 (Nasal/sinus endoscopy, surgical; with ethmoidectomy, total [anterior and posterior]) is a Column 2 code for 31292 (… with medial or inferior orbital wall decompression), meaning the work associated with 31255 is part of 31292. However, a modifier is allowed in order to differentiate between the services provided (such as 59, Distinct procedural service). However, in order to use the modifier, the surgeon must perform the ethmoidectomy on a different side from the orbit wall decompression.

Best bet: Also include either modifier RT (Right side) or LT (Left side) along with the 59 modifier, if the surgeon performed the total ethmoidectomy on different side than the medial or inferior orbital wall decompression. If both procedures were performed on same side, you cannot bill 31255 with 31292 as it will be considered included in the main procedure.