Otolaryngology Coding Alert

Coders may have noticed that the five codes at the end of the Sinus Endoscopy section of CPT 2002 differ from other functional endoscopic sinus surgery (FESS) codes in three ways: 1) the nature and complexity of the procedures they describe, 2) the number of days in the surgical package (10 global days versus 0 global days for most other FESS procedures) and 3) the number of relative value units (RVUs) assigned (26-33 RVUs versus 4-16 RVUs for most FESS procedures).
 
The codes include:

31290 nasal/sinus endoscopy, surgical, with repair of cerebrospinal fluid leak; ethmoid region

31291 sphenoid region

31292 nasal/sinus endoscopy, surgical; with medial or inferior orbital wall decompression

31293 with medial orbital wall and inferior orbital wall decompression

31294 with optic nerve decompression.    

 
Codes 31290-31291 include repairs to cerebrospinal fluid (CSF) leaks that were performed as open procedures before the advent of endoscopic procedures, says Sanford Archer, MD, an otolaryngologist and associate professor at the University of Kentuckys College of Medicine in Lexington, Ky., chairperson of the Patient Safety and Quality Improvement Committee of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) and a member of the academys Rhinology and Paranasal Sinus Committee. Repairing a CSF leak endoscopically lessens the risk to the patient. Previously, when the procedure was performed using craniotomy (pulling back the frontal lobe), damage to the olfactory system often resulted, and there was a greater risk of visual damage to the optic nerves, Archer says.
 
To repair a CSF leak in the ethmoid region, the ethmoid sinus is entered, the leak is isolated, and grafts or flaps may be used to seal the leak. To repair a sphenoid leak, the endoscope may enter the sphenoid directly through the septum or via the ethmoid sinuses.
 
Ethmoidectomy 31254 (nasal/sinus endoscopy, surgical; with ethmoidectomy, partial [anterior]) or 31255 ( with ethmoidectomy, total [anterior and posterior]) may not be billed if it is performed to provide access to the CSF leak repair. If the otolaryngologist discovers a CSF leak while performing an ethmoidectomy or if the patient develops a CSF leak during the surgery, however, ethmoidectomy may be billed along with 31290, says Melissa Pointer, CPC, billing manager with the otolaryngology division at the University of Arkansas Medical Center in Little Rock.
 
Pointer says that modifier -59 (distinct procedural service) should be appended to the appropriate ethmoidectomy code or other FESS code in such cases to let the carrier know that the ethmoidectomy was performed first for a separate reason. The ethmoidectomy should be linked to a separate diagnosis code (for example, 473.2 [chronic ethmoidal sinusitis]); 31290 should also be linked to a related diagnosis code (for example, 349.81 [cerebrospinal fluid rhinorrhea]).

 
Codes 31292-31294 include decompressions of the orbital wall (the bone surrounding the eye) and optic nerve, which ophthalmologists (rather than otolaryngologists) performed as open procedures before the advent of endoscopic procedures.
 
An otolaryngologist performing inferior and/or medial orbital wall decompression endoscopically may still want to have an ophthalmologist on hand to perform lateral canthotomy with orbital decompression to relieve pressure on the superior orbital wall, which cannot be accessed by an endoscope, Archer says.
 
Decompression procedures are typically performed on patients with Graves disease (242.0), a thyroid condition that increases pressure in the orbit and causes bulging of the eyes. An endoscopically guided total ethmoidectomy is performed, the lamina papyracea is taken down and the periorbita is striped with a sickle knife to decompress the orbital fat into the sinus. A similar technique can be used to take down the orbital floor through an enlarged maxillary ostia if needed.
 
To select the correct endoscopic code when orbital wall decompression is performed, the documentation must indicate whether the medial and inferior walls were decompressed. Use 31292 if endoscopic surgery was performed on one wall only; use 31293 if both walls were decompressed.
 
Code 31294 describes decompression of the optic nerve. When this procedure is performed bilaterally, report 31294 with modifier -50 (bilateral procedure) or with modifiers -LT (left side) and -RT (right side) appended.
 
As with CSF leaks, other FESS surgeries that may be performed with the orbital wall or optic nerve decompression (such as ethmoidectomies, maxillary antrostomy or sphenoidotomy) may not be reported separately if they are performed solely to access the orbital wall.
 
However, if the otolaryngologist completes the decompression and then treats sinusitis via regular FESS (i.e., ethmoidectomy, maxillary antrostomy or sphenoidotomy), the procedures may be paid separately (depending on the carrier).
 
The decompression codes do not bundle regular FESS procedures in the CCI, so Medicare carriers are likely to pay separately for the two procedures in these instances. Private payers, however, may balk at paying for both procedures.
 
It may help to append modifier -59 to the appropriate FESS procedure to let the commercial payer know the procedures were distinct and should be paid separately, as long as this is clearly documented in the operative report.

Global Period

 
Codes 31290-31294 have a 10-day global period, which means that any debridements or E/M services performed within 10 days may not be paid separately, Pointer says. She notes, however, that if the patient is returned to the operating room for a complication, the procedure performed could be billed with modifier -78 (return to the operating room for a related procedure during the postoperative period) appended to the procedure code. Any debridements or E/M services after 10 days are paid separately, she adds.
 
Note: As with all surgical endoscopies, any diagnostic endoscopy performed during the same session is included in the surgery.