Explore 2018 Changes for Otolaryngology
Here’s the clarity you need to use new procedure codes, modifiers, and bundling rules correctly.
CPT® 2018 introduces important changes for nasal/sinus endoscopy coding, including several new codes that bundle endoscopic procedures often performed together. Let’s explore these new codes, as well as other important additions and revisions.
New Ethmoidectomy Codes Bundle Sphenoidotomy and More
Three new codes describe procedures performed at the same time as nasal/sinus endoscopy with total ethmoidectomy (removal of tissue from anterior and posterior ethmoid sinus):
31253 Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including frontal sinus exploration, with removal of tissue from frontal sinus, when performed
31257 total (anterior and posterior), including sphenoidotomy
31259 total (anterior and posterior), including sphenoidotomy, with removal of tissue from the sphenoid sinus
The new codes combine services reported by existing codes for procedures performed at the same time on the same (ipsilateral) side, as shown:
2018 Bundled Code Component Codes
31253 31255 and 31276
31257 31255 and 31287
31259 31255 and 31288
As of Jan. 1, for total ethmoidectomy with frontal sinus exploration (with or without removal of the frontal sinus), you must report 31253 rather than 31255 and 31276. Both of these codes have descriptor changes this year, as explained in the Descriptor Clarification section below.
CPT® provides parenthetical instruction following each of the new codes to avoid unbundling of services. For example, parenthetical instruction following 31259 warns, do not report “with 31254, 31255, 31257, 31287, 31288, 31297, 31298, 0406T, 0407T on the ipsilateral side.”
Bundling Gone Bad
If you have been coding and billing otolaryngology services since the early 1990s, you may remember when the American Medical Association (AMA) changed the CPT® codes for functional sinus surgery into a series of bundled codes in 1994.
In 1994, we had codes for:
- Partial ethmoidectomy
- Partial ethmoidectomy with maxillary antrostomy
- Partial ethmoidectomy with maxillary antrostomy with removal of antral mucosal disease
- Partial ethmoidectomy with frontal sinus exploration
- Partial ethmoidectomy with frontal sinus exploration and maxillary antrostomy
- Partial ethmoidectomy with frontal sinus exploration and maxillary antrostomy with removal of antral mucosal disease
We had a similar set of codes for total ethmoidectomy alone, with maxillary antrostomy, with removal of antral mucosal disease, etc. We also had codes for total ethmoidectomy and sphenoidotomy with or without removal of polyps, with antrostomy, with antrostomy and removal of antral mucosal disease, with frontal exploration, etc.
These “bundling” codes caused such a flurry of confusion and problems that, one year after the codes were introduced, CPT® introduced 31254-31276, as we know them now.
Two codes within the same family as 31253, 31257, and 31259 are revised for editorial consistency, without changing the intended use of the codes:
31254 Nasal/sinus endoscopy, surgical with ethmoidectomy; with ethmoidectomy, partial (anterior)
31255 with ethmoidectomy, total (anterior and posterior)
Code 31276 Nasal/sinus endoscopy, surgical, with frontal sinus exploration, including removal of tissue from frontal sinus, when performed is similarly revised for consistency. Note that 31276 (valued at 14.44 relative value units (RVUs), as of Nov. 1, 2017) is more than a “look around” at the frontal sinuses. Work must be performed to open the sinuses. If documentation indicates only that the “frontal sinuses are patent,” this work is considered part of an anterior ethmoidectomy, 31254.
A new parenthetical note instructs, “Do not report 31276 in conjunction with 31253, 31255, 31296, 31298 when performed on the ipsilateral side.”
Surgical Endoscopy with Balloon Dilation Gets a Bundled Code
Another new code for 2018 bundles surgical nasal/sinus endoscopy with balloon dilation of the frontal and sphenoid sinus ostia:
31298 Nasal/sinus endoscopy, surgical; with dilation of frontal and sphenoid sinus ostia (eg, balloon dilation)
Per CPT® instruction, do not report 31298 with either 31296 Nasal/sinus endoscopy, surgical; with dilation of frontal sinus ostium (eg, balloon dilation) or 31276. And do not report 31298 with 31235, 31257, 31259, 31287, 31288, 31296, or 31298 if performed on the ipsilateral side. This clarification supports billing functional endoscopic sinus surgery (FESS) codes when they are performed on the contralateral (opposite) side with modifier 59 Distinct procedural service, or modifier XS Separate structure for Medicare.
Endoscopy with Sphenopalatine Ligation Gains a Code
Another new code reports ligation of the sphenopalatine artery during a nasal/sinus endoscopy:
31241 Nasal/sinus endoscopy, surgical; with ligation of sphenopalatine artery
Previously, this service was reported using an unlisted procedure code (e.g., 30999). Per CPT®, do not report 31241 with 31238 Nasal/sinus endoscopy, surgical; with control of nasal hemorrhage when performed on the ipsilateral side.
More Code Changes
Code 31320 is deleted for 2018 due to low volume of usage. New technologies and techniques have replaced this procedure.
The descriptor for 31645 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with therapeutic aspiration of tracheobronchial tree, initial is revised to apply specifically to an initial therapeutic aspiration of tracheobronchial tree by bronchoscopy. For a subsequent procedure of the same type during the same hospital stay, see revised code 31646 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; subsequent, same hospital stay. CPT® adds a note, “For catheter aspiration of tracheobronchial tree with fiberscope at bedside, use 31725 [Catheter aspiration (separate procedure); tracheobronchial with fiberscope, bedside].
Endoscopy Section Header Text Revisions
For 2018, CPT® also revises text introducing the nasal endoscopy codes. One important addition is the instruction, “Stereotactic computer-assisted navigation may be used to facilitate the performance of endoscopic sinus surgery, and may be reported with 61782.” This should help if a payer denies +61782 Stereotactic computer-assisted (navigational) procedure; cranial, extradural (List separately in addition to code for primary procedure) when coded with sinus surgery.
The text also adds information to diagnostic evaluations, 31231-31235. The code book now indicates:
To report these services when all of the elements are not fully examined (eg, judged not clinically pertinent), or because the clinical situation precludes such exam (eg, technically unable, altered anatomy), append modifier 52 if repeat examination is not planned, or modifier 53 if repeat examination is planned.
Modifier 53 Discontinued procedure is appropriate from a payer’s perspective because it’s expected the procedure will be repeated, coded, and billed at a later date.