Outpatient Facility Coding Alert

Question: One of our third-party insurers has sent two denials for claims with code 31295 on the grounds of it being investigational. The hospital got paid and we did not. Do you have any suggestions?

North Carolina Subscriber 

Answer: If your physician performs 31295 (Nasal/sinus endoscopy, surgical; with dilation of maxillary sinus ostium [e.g., balloon dilation], transnasal or via canine fossa) at a hospital, you'll only get a small reimbursement and the hospital will be paid for the actual balloon.  

If the surgeon performed only a balloon dilation of the maxillary sinuses without removing tissue, you are correct to report 31295. Appeal the denial with your documentation and fight to get it paid. 

If your surgeon did remove tissue, you are not supposed to code the balloon dilation. Instead, you should bill the traditional FESS code, 31267 (Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus). If this is the case, you will also need to appeal the denial with a corrected claim and a copy of the operative note.  If your physician is a member of the AAO/HNS, you can include the instructions from the AAO/HNS website which tells you to code the traditional FESS code when tissue is removed. That letter can be found in the ENT section of the CPT^® manual for members of the Academy.