New FESS Codes for 2018
- By Barbara Cobuzzi
- In Coding
- January 10, 2018
- 25 Comments
2018 brings us new functional endoscopic sinus surgery codes (FESS) which bundle a total ethmoidectomy with both a frontal sinusotomy and a sphenoidotomy with and without removal of tissue. 2018 CPT® also provides a new bundled code for a frontal and sphenoid endoscopic balloon dilation. On initial review of these new codes and the instructions in the AMA CPT® code book, it is confusing as to how to one should code when 3 or 4 sinuses are operated on the same side.
Nasal Sinus Endoscopy
According to the American Rhinologic Society, several nasal sinus endoscopy services were identified as potentially misvalued because billing patterns revealed they were billed together more than 75 percent of the time (same beneficiary/same day of service). As a result, the specialty societies were required to ‘bundle’ services together and create new codes that represented the combined services.
When services are bundled, the Centers for Medicare & Medicaid Services (CMS) expects to see significant reductions in work relative value units (wRVUs) to account for inefficiencies. CMS finalized 2018 values for five new nasal sinus endoscopy CPT codes (31241, 31253, 31257, 31259, and 31298) and 10 existing nasal sinus endoscopy CPT codes.
Balloon Sinus Dilation Codes
|31295||Nasal/sinus endoscopy, surgical; with dilation of maxillary sinus ostium (eg, balloon dilation), transnasal or canine fossa||2.70||2.70||000|
|31296||Nasal/sinus endoscopy, surgical; with dilation of frontal sinus ostium (eg, balloon dilation)||3.29||3.10||000|
|31297||Nasal/sinus endoscopy, surgical; with dilation of sphenoid sinus ostium (eg, balloon dilation)||2.64||2.44||000|
|New/Bundled||31298||Nasal/sinus endoscopy, surgical; with dilation of frontal and sphenoid sinus ostia (eg, balloon dilation)||*4.61||4.50||000|
Functional Endoscopic Sinus Surgery (FESS) Codes
|31254||Nasal/sinus endoscopy, surgical with ethmoidectomy; partial (anterior)||4.64||4.27||000|
|31255||Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior)||6.95||5.75||000|
|New/Bundled||31253||Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including frontal sinus exploration, with removal of tissue from frontal sinus, when performed||*12.30||9.00||000|
|New/Bundled||31257||Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including spehnoidotomy||*8.90||8.00||000|
|New/Bundled||31259||Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including sphenoidotomy, with removal of tissue from sphenoid sinus||*9.24||8.48||000|
|31256||Nasal/sinus endoscopy, surgical, with maxillary antrostomy||3.29||3.11||000|
|31267||Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus||5.45||4.68||000|
|31276||Nasal/sinus endoscopy, surgical; with frontal sinus exploration, including removal of tissue from frontal sinus, when performed||8.84||6.75||000|
|31287||Nasal/sinus endoscopy, surgical, with sphenoidotomy||3.91||3.50||000|
|31288||Nasal/sinus endoscopy, surgical, with sphenoidotomy; with removal of tissue from the sphenoid sinus||4.57||4.10||000|
*Computed using 2017 wRVUs and the standard multiple procedure payment reduction methodology
New Sphenopalatine Artery Code
|31241||Nasal/sinus endoscopy, surgical; with ligation of sphenopalatine artery||8.00||000|
It makes sense that a partial and total ethmoidectomy are bundled with the new codes, 31253, 31257, and 31259 since each of the new codes includes a total ethmoidectomy. A maxillary antrostomy still stands alone and is not included in any of the codes, so the combination codes only include the anterior and posterior ethmoid sinuses along with the frontal and sphenoid sinuses. So if a maxillary antrostomy is performed with a total ethmoidectomy and a frontal sinusotomy on the same side, it would be coded with the combination codes 31253 plus 31256 if no tissue was removed and plus 31267 if tissue was removed. If a maxillary antrostomy, total ethmoidectomy, and sphenoidotomy are performed on the same side, there are a few combinations of codes that may apply, depending if tissue was taken out of the maxillary sinuses and/or sphenoid sinuses.
31257 and 31256 if no tissue was removed from either maxillary or sphenoid sinuses
31257 and 31267 if tissue is only removed from the maxillary sinus
31259 and 31256 if tissue is only removed from the sphenoid sinus
31259 and 31267 if tissue is removed from both the maxillary and sphenoid sinuses
CMS finalized direct practice expense inputs for this family of services as well as including updates to the “sinus surgery balloon (maxillary, frontal, or sphenoid) kit.” CMS included 0.5 kits for CPT codes 31295, 31296, and 31297 and one kit for CPT code 31298. The specialty societies urged the Agency to develop a standalone HCPCS Level II supply code for the balloon kit, to allow providers flexibility in reporting the quantity of actual kits used. CMS rejected the request.
The question is how will it be coded if all four sinuses are operated on the same side? The American Medical Association (AMA) should be issuing guidance for this via CPT® Assistant soon, but in the meantime, guidance from high ranking physicians of the AAO/HNS have indicated the following:
All four sinuses (with no removal of tissue) can be coded in one of two ways:
31253, 31287, 31256 or 31257, 31276, 31256
If tissue is removed, 31287 and/or 31256 would be replaced with 31288 and/or 31267 in the first coding combination or 31257 and/or 31256 would be replaced with 31259 and/or 31267.
Resection Inferior Turbinate (CPT 30140)
CMS finalized work and direct practice expense inputs for CPT code 30140 Submucous resection inferior turbinate, partial or complete, any method, a service that was identified as potentially misvalued on a screen of Harvard-valued codes with utilization over 30,000.
CMS assigned a wRVUs of 3.00 for CY2018. CMS also finalized direct practice expense inputs for CPT Code 30140, which included three new equipment codes based on the invoices submitted for this code family: a 2mm reusable shaver blade (EQ383), a microdebrider handpiece (EQ384) and a microdebrider console (EQ385).
It is important to note that CMS changed the global period from a 090 day global period to a 000 day global period for CPT code 30140. This change in in global period from 090 to 000 will allow providers to bill for follow-up care performed. This change in global period puts 30140’s global period out of sync with the global period for the other turbinate procedures, 30130 Excision inferior turbinate, partial or complete, any method which still has 90 global days, 30801 Ablation, soft tissue of inferior turbinates, unilateral or bilateral, any method (eg, electrocautery, radiofrequency ablation, or tissue volume reduction; superficial and 30802 Ablation, soft tissue of inferior turbinates, unilateral or bilateral, any method (eg, electrocautery, radiofrequency ablation, or tissue volume reduction); intramural (ie, submucosal), both of which still have 10 global days.
|30140||Submucous resection inferior turbinate, partial or complete, any method||3.57||3.00||090||000|
- Coding Uncertain Lesion Excisions With Certainty - August 1, 2022
- CDI Tips for Diagnostic Endoscopies - May 2, 2022
- Medicare Telehealth Coding as of April 30 - May 1, 2020
We have contacted a few of our insurance companies and they do not have allowable for these codes new bundling codes for sinuses….. They say they are not aware of code changes. Should all insurances be aware of these changes? Is their a grace period on using these codes?
Thank you for your help..
Rosanne Darley, HIPAA standardized codes sets say that payers must use the same code sets. You need to inform your payer that they have to update their systems to 2018 CPT. The only payers who are exempt from updating to the current codes are Motor Vehicle (PIP) and Workers Comp payers. They can get away with using old codes and driving you crazy. All other payers must update and use the current codes.
Our Dr. is wanting to report 31298-Right, 31295-50 and 31296-Left. Is this okay to report together? I would report with LT/RT modifiers but it is a Noridian Medicare member and Medicare will not allow RT/LT modifiers. The claim will just get kicked back for invalid Modifier. Please advise.
There still seems to be much confusion regarding how to bill these new codes for removal of tissue in all 4 sinuses. If we bill one of the two examples above(FESS Question) 31288/31267 or 31259/31267 are we being reimbursed for the frontal as well?
Neither of the two examples you list (31288/31267 or 31259/31267) include the frontal sinuses. The first one includes the sphenoid and maxillary sinuses only and the second the ethmoids, sphenoid and maxillary sinuses. When billing for all 4 sinuses, you need to add 31276 to 31259 and 31267 (assuming tissue was removed from the maxillary and sphenoid sinuses)
So, it appear that your provider performed a maxillary BSD bilaterally, frontal BSD bilaterally and sphenoid BSD on the left. You would report this as: (Since your Medicare carrier does not like the LT and RT modifiers, do not use them. I included them so you can see what side is being addressed
The XS is in place of a 59 modifier and refers to separate structure.. This is saying that this frontal BSD is on a separate structure than the frontal BSD is reflected from 31298.
Bilateral frontal, bilateral ethmoidectomy w/removal of tissue and LT sphenoidotomy w/removal of tissue were performed. How should this be billed to a commercial insurance?
Lisa, for the bilateral frontal, bilateral ethmoid and LT sphenoidotomy with removal of tissue, I would code:
31253-50. 150% of 12.3 RVUs
31288-RT. 50% of 4.57 RVUs
This will optimize payment for the surgery you describe.
Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO
Hi – I would like to make sure I understand CPT 31298. Does 31298 just include the frontal and sphenoid ? Or does it also include the maxillary ? When doing bilateral BSD I would normally bill 31298-50 and 31295-50. Is this correct ? Thank you.
31298 includes a BSD of the frontal and sphenoid. If all three sinuses were dilated via balloon, you would code it 31298, 31295. If all three sinuses were dilated via balloon bilaterally, you are correct, it would be coded 31298-50, 31295-50. Make sure you link the frontal and sphenoid sinusitis diagnoses to 31298 and the maxillary sinusisits linked to 31295. Tell your doctor to list the specific sinuses that are effected and to not just list “chronic sinusitis” and/or “acute sinusitis” in the pre/post op diagnosis on the op note which would force you to use “unspecified” codes. The coder needs specific diagnoses in order to support medical necessity for the multiple BSD procedures performed.
I did bilateral frontal and ethmoid FESS and used 31253 – 50. We received a denial stating the modifier is incorrect. We tried calling the insurance but they could not tell us how to properly bill it. Should we try:
31253 – 51 RT
31253 – LT
KW, The insurance company is wrong, 31253 is payable with a 50 modifier. They seem to have their computer systems set up improperly. Since you are dealing with people who do not understand the anatomy and do not have their system set up properly, you can do one of two things. I would appeal the non payment of the bilateral surgery and point out to the payer that they have their systems set up wrong. I would show them that the Medicare fee database indicates that the 50 modifier is a payable modifier when the frontal and ethmoid FESS surgery was performed bilaterallly. I would fight with the payer tooth and nail because of their inappropriate processing of the claim.
The other way you can try to bill the surgery would be:
I do not think the 51 modifier would get the second side paid. The 59 modifier is showing that it is a separate site.
What if I have Bilateral Ethmoids and a Left Frontal?
How do I use the bundled code 31253 and specify bilateral just or the ethmoids and left just for the frontal?
For bilateral total ethmoidectomy and left frontal, you would code
31255-59-RT (If this is a Part B Medicare patient, it would be 31255-XS-RT)
Hi – We have always done a sinus debridement (31237-50-79) post operative with modifier -79. They are now being denied for the procedure code is inconsistent with the modifier used or invalid modifier. We have tried -78 which now reads unplanned return to OR/Procedure room by same physician or other qualified health care professional during post op period and -78 is rejected for the same reason – procedure code is inconsistent with the modifier used . What should we be using ? Modifier -58 staged or related ? Thank you for your help. Tammy
The -78 modifier would not be applicable. If the 79 modifier is not being accepted by your payer, the other alternative is the 58 modifier for staged procedure since the provider plans on doing the debridements post sinus and septum surgery. Note that 30140 has gone down to zero global days in 2018 from 90 days in 2017 or earlier. So, if your surgeon performed FESS surgery and a submucous resection of the turbinates, the surgery has zero global days in 2018. Unfortunately, if the lesser service, a coblation of the turbinates, 30802 is performed, the surgery has a 10 day global since the other turbinate codes’ global periods were not changed to be consistent with 30140.
Make sure you pre-certify the planned debridement services. That way, when using the 58 modifier, you will have pre-notified the insurance company of your plans to perform debridements. I recommend pre-certifying the debridements no matter which modifier is used (79 or 58) because it is always better to give the insurance company the information up front and have the procedures pre-certified.
I have a Dr. who is wanting to bill 31255-Rt, 31254-LT,31267-50,31288-50 and 31276-50. How do you suggest I code this with new bundled codes? Please advise.
Greetings from the Washington DC Regional Conference, Nicole,
In order to optimize your RVUs, you want to use the combination code for the sphenoidotomy with removal of tissue and total ethmoidectomy on the right. I would code this surgery:
31276-50-59 (or XS if the patient is enrolled in Medicare Part B)
31254-59-LT (or XS if the patient is enrolled in Medicare Part B)
31288-59-LT (or XS if the patient is enrolled in Medicare Part B)
The 59 or XS if the patient is enrolled in Medicare Part B is needed for the 31276, 31254 and 31288 because they are all bundled into other codes but in this case they are not bundled because they are performed on the opposite side.
I hope this helps.
Barbara J. Cobuzzi MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO
I have a provider who has been billing 31295, 31296, 31297 all with RT/LT modifiers and sometimes adding 30520 as well. Is this possible? No he is occasionally billing 31298 (RT/LT) along with 31295 (RT/LT) and 30802 (RT/LT). I’m curious what you think of these combinations.
I watched a webinar out on by another company and they have billed the 31259 and 31253 together. I haven’t found any edits against it but I’m curious as to whether this is acceptable or not? I feel like this would be double dipping?
We are being audited by outside auditors, they are saying that is ok, they have no edits saying we can not bill 31253 along with either 31257 or 31259.. is this correct? We have not been coding our charts this way and have been being paid with the frontal stand alone code 31276 with either 31257 or 31259. I feel billing/coding the 31257/31259 along with the 31253 is double billing for the ethmoid?? Please help
We are being audited by outside auditors and they are stating it is ok to bill 31253 along with 31257/31259. They have no edits, others are getting paid, and they have seen it stating It should be billed this way as well. We have been billing it as 31257/31259 then 31276 and that has been getting paid right along. We feel billing the 31253 along with either 31257/31259 would be double billing for the ethmoid?? Please help
Here is what I found today on this subject if it helps anyone. If you find anything otherwise please let me know.
The new 2018 codes 31253, 31257 & 31259 include the work of 31255, according to CPT® Assistant. April 2018; Volume 28: Issue 4, Updated Endoscopic Nasal/Sinus Surgery Codes for 2018. Therefore it would make sense that the three new codes should not be billed together on the same day. For example, if performing nasal /sinus endoscopy, surgical with ethmoidectomy total (anterior / posterior), including bilateral frontal sinus exploration, with removal of tissue from frontal sinus AND bilateral sphenoidotomy, with removal of tissue from sphenoid sinus, an appropriate code combination would be 31253-50 and 31288-50, not 31253-50 & 31259-50. The 2018 CPT book indicates you should not bill 31255 with any of the new codes, when performed on the ipsilateral side, so it would make sense that you also should not bill the new codes with each other since they each include the work of 31255. I would agree it is confusing! I have no idea why there is not a CCI edit stopping the new codes from being billed together. Hoping there is more clarification coming from the AMA on this.
I have a question about cpt 31237 and billing an e&m code. I was always told not to bill an office visit and a debridement together. Can someone advise me?
I am billing the following and I am wondering what I can change so I can get reimbursement on cpt 31297 and 30930.
I billed: 31297-50,51, 31296 Lt, Rt-51, 31295-Lt-51, Rt-51, 30520-51, 31255-Lt51, Rt51, 30140-Lt51, Rt51,