Otolaryngology Coding Alert

Question: A patient has a large mass growing from the sinus that actually goes into the mouth. For this complicated procedure, is there a second code we can use beside 31267 (Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus)?

Pennsylvania Subscriber

Answer: Although the actual coding will depend on the operative report, the otolaryngologist may end up performing a Caldwell-Luc. If during the endoscopic maxillary antrostomy, the surgeon uses the scope inside the maxillary sinus but cannot access and remove all the polyps and masses, the patient may require an open C-L antrostomy, entering the maxillary tissues through the gum line.

  In this case, you would code the C-L with removal of tissue (31032, Sinusostomy, maxillary [antrostomy]; radical [Caldwell-Luc] with removal of antrochoanal polyps) and the appropriate functional endoscopic sinus surgery (FESS) ethmoidectomy (either 31254, Nasal/sinus endoscopy, surgical; with ethmoidectomy, partial [anterior] or 31255, - with ethmoidectomy, total [anterior and posterior]). You may bill an endoscopic procedure performed on another sinus in addition to open maxillary antrostomy. The insurer may reduce payment for the ethmoidectomy 50 percent following Medicare multiple procedure rules.

Watch out: FESS procedures have zero global days, whereas open surgeries (such as C-L) have 90-day global periods. The C-L procedure would include any subsequent related services, such as follow-up visits or debridements.

If the surgeon endoscopically begins the maxillary procedure and then during the surgery has to convert to an open procedure, you would bill only 31032. Medicare guidelines state that when an endoscopic procedure is converted to open, only the open procedure is billed.

Although CPT states that you may bill both procedures with 52 (Reduced services) appended to the endoscopic procedure that was not completed, most private payers follow Medicare's lead on this issue and will pay only for the open procedure. The operative report should clearly indicate why the endoscopic procedure was converted to open surgery.

Tip: If the completed, converted endoscopic procedure plus the open procedure consumed a lot of time and effort, consider appending modifier 22 (Increased procedural services) to 31032. Submit the claim electronically and then send in documentation with a cover letter explaining the increased work.