Otolaryngology Coding Alert

Never ‘code for dollars’ by submitting higher RVU values.  

The difference in reimbursement between FESS procedures is significant, which makes verifying your codes against your surgeon’s documentation even more important.

For example, 31256 (Nasal/sinus endoscopy, surgical, with maxillary antrostomy) is assigned 5.71 relative value units (RVUs) by the National Physician Fee Schedule Relative Value Guide; code 31267 (Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus) has 9.16 RVUs. The payment difference between 31287 (Nasal/sinus endoscopy, surgical, with sphenoidectomy) with 6.69 RVUs and 31288 (Nasal/sinus endoscopy, surgical, with sphenoidotomy; with removal of tissue from the sphenoid sinus) at 7.76 RVUs also is noteworthy. In other words, your otolaryngologist’s documentation and your code choice can significantly affect reimbursement. 

Also remember that both 31267 and 31288 usually are secondary procedures accompanying ethmoid endoscopies (31254,nasal/sinus endoscopy, surgical; with ethmoidectomy, partial [anterior]; and 31255,... with ethmoidectomy, total [anterior and posterior]). Because both ethmoidectomies are assigned more RVUs than the sphenoid tissue removal, you should list 31288 after either 31254 or 31255 when billing for the procedures. Maxillary tissue removal would be listed ahead of 31254 but below 31255 on the CMS 1500 form.

Note: If the surgeon performs any of these sinus endoscopies bilaterally, the sequence would change, depending on which procedures were bilateral and which were performed on one side only. Base your code order on the 150 percent of RVUs for the bilateral procedure versus the 100 percent RVUs for the unilateral service – the procedure with the highest RVUs goes first on the claim.