Multiple Endoscopy Rule Examples

In my last blog “Special Rules Apply to Endoscopic Sinus Surgeries,” I discussed the change to the Multiple Endoscopy Rule for multiple surgeries when performed within the family of endoscopic sinus codes.

How Does the Multiple Endoscopy Rule Affect Payment?

Using the multiple endoscopy rule with the base code 31231 Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure) pays more for each surgery in 2020 compared to in 2019. This increase results even though each individual CPT® code allowance in 2020 has been reduced when compared to 2019. This may not always be the case when the second surgery is valued close to the value of 31231, but it appears to be the case in most scenarios.
The second and third surgeries are reduced by the value of 31231 based on the site of service. When the site of service is in the office, the reduction is $197.77, and when the site of service is in the operating room, the reduction is $65.68. (These fees are based on Medicare’s national fee schedule, without any geographical adjustments.)
The multiple endoscopy rule has been implemented by Medicare Part B. It is not clear how the payment of multiple surgeries will be processed by non-Part B Medicare payers. Do not assume that all payers are necessarily following Medicare’s rules, particularly to start. It may take time for commercial payers to align themselves with Medicare.
Table 1 shows the Medicare fees for nasal endoscopy codes in 2019 and 2020 (without any geographical adjustment).
Table 1: Medicare fees for nasal endoscopy
Facility Fees                                     Non-facility Fees

5 Examples for How the Multiple Endoscopy Rule Affects Payment

Example 1:

Doctor performs bilateral total ethmoidectomy, bilateral sphenoidotomy with removal of tissue, bilateral frontal sinusotomy in the OR.

Example 2:

Doctor performs bilateral maxillary balloon sinus dilation and a right sided sphenoid balloon sinus dilation in the office.

Example 3:

Doctor performs endoscopic right concha bullosa removal, bilateral total ethmoidectomy, bilateral maxillary antrostomy with removal of tissue in the OR.

Example 4:

Doctor performs a unilateral left sided anterior ethmoidectomy, left sided frontal sinusotomy, left sided maxillary antrostomy and a right sided diagnostic endoscope to ensure that there is no disease that might be missed on the right side.  This surgery was performed in the OR.
Note: If the payer involved does not acknowledge the X[ESPU] MODIFIERS for separate procedures, modifier 59 should be used in their place.  All Medicare Part B Carriers recognize the X[ESPU] MODIFIERS.

Example 5:

Doctor performs a bilateral frontal balloon sinus dilation, unilateral sphenoid balloon sinus dilation on the left and a bilateral maxillary balloon sinus dilation. This surgery was performed in the office.
Note: If the payer involved does not acknowledge the X[ESPU] modifiers for separate procedures, modifier 59 should be used in their place. All Medicare Part B carriers recognize the X[ESPU] modifiers.

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Barbara Cobuzzi

Barbara J. Cobuzzi, MBA, CPC, COC, CENTC, CPC-P, CPC-I, CPCO, CMCS, is CEO of CRN Healthcare Solutions and formerly owned a medical billing company. Cobuzzi is a subject matter expert in otolaryngology coding. She provides litigation support as an expert witness for providers and payers and often presents for many local and national organizations. She is also a consulting editor for AAPC’s Otolaryngology Coding Alert newsletter. In 1999, Cobuzzi was named AAPC’s Networker of the Year, and she is a past member of the National Advisory Board. She is one of four founding members of the Monmouth/Ocean, N.J., local chapter and is still active with the chapter.

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