Otolaryngology Coding Alert

Question: Our surgeon performed a right-sided ethmoidectomy and right-sided maxillary antrostomy. How will reimbursement in 2020 compare to 2019?

Michigan Subscriber

Answer: First, you want to address the higher value code, 31255 (Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior)), which will be reimbursed in full as a unilateral procedure with modifier RT (Right Side). The 2019 Medicare Physician Fee Schedule (MPFS) fee for 31255 is $336.24. As the highest value code, you don’t need to consider making further reductions, since the multiple procedure reduction only applies to codes that are secondary to the code with the highest relative value units (RVUs). The 2020 fee for 31255 is $335.99. The same rules apply here, so the difference between 2019 and 2020 is only a few cents on the dollar.

Next, you’ve got to do some additional calculations in order to get the correct 2020 charge for code 31267 (Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus) with modifier RT. To determine the 2019 fee, you’ll divide the 2019 fee of $275.70 in half, following the multiple procedure guidelines, to leave you with a charge of $137.85. For the 2020 fee, you’ll be subtracting the value of the base code, 31231 (Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure)), from the 2020 fee of code 31267-RT. This means you’ll subtract the 2020 fee of 31231 from 31267 ($274.64-$65.68), resulting in a charge of $208.96.

As you can see, the application of the new special rules for multiple endoscopies leaves you with a negligible difference between the highest value codes, but substantially increases the fee for secondary procedures. You’ll find this fee increase for secondary procedures to be universal across functional endoscopic sinus surgery (FESS) codes when comparing the reduction of the base code to the multiple procedure reduction rule.