Multiple Endoscopy Rule Examples

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

CPT® Code 2019 2020 2019 2020
31231 $    67.03 $    65.68 $  205.06 $  197.77
31233 $  139.47 $  138.58 $  291.75 $  268.87
31235 $  165.06 $  163.85 $  305.25 $  306.40
31237 $  165.06 $  163.85 $  261.64 $  260.21
31238 $  172.99 $  172.15 $  258.40 $  256.60
31239 $  633.21 $  628.32 $  633.21 $  628.32
31240 $  164.34 $  163.12 $  164.34 $  163.12
31241 $  462.74 $  460.83 $  462.74 $  460.86
31254 $  252.63 $  251.91 $  424.54 $  432.71
31255 $  336.24 $  335.99 $  336.24 $  335.99
31253# $  520.40 $  519.69 $  520.40 $  519.69
31257# $  464.18 $  462.67 $  464.18 $  462.67
31259# $  491.57 $  489.74 $  491.57 $  489.74
31256 $  187.04 $  186.58 $  187.04 $  186.58
31267 $  275.70 $  274.64 $  275.70 $  274.64
31276 $  393.55 $  391.93 $  393.55 $  397.93
31287 $  209.03 $  208.60 $  209.03 $  208.60
31288 $  243.26 $  242.16 $  243.26 $  242.16
31290 $1,182.44 $1,180.49 $1,182.44 $1,180.49
31291 $1,259.57 $1,261.33 $1,259.57 $1,261.33
31292 $1,022.07 $1,025.67 $1,022.07 $1,025.67
31293 $1,110.36 $1,108.31 $1,110.36 $1,108.31
31294 $1,271.46 $1,269.27 $1,271.46 $1,267.27
31295 $  163.98 $  163.12 $2,004.86 $1,932.24
31296 $  186.32 $  185.86 $2,031.16 $1,958.58
31297 $  149.20 $  148.69 $2,174.56 $1,917.08
31298 $  265.61 $  264.90 $4,197.53 $3,685.11

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.

Code Description 2019 Fee 2020 Fee
31253-50 Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including frontal sinus exploration, with removal of tissue from frontal sinus, when performed $520.40*1.5 = $780.60 $519.69*1.5 = $779.54
31288-50 Nasal/sinus endoscopy, surgical, with sphenoidotomy; with removal of tissue from the sphenoid sinus ($243.26*1.5)*0.5 =              $182.45 ($242.16*1.50) – Base code ($65.68) = $297.56
TOTAL   $  963.05 $1,077.10

Example 2:

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

Code Description 2019 Fee 2020 Fee
31295-50 Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); maxillary sinus ostium, transnasal or via canine fossa $2,004.86*1.5 = $3,007.29 $1,932.24*1.5 = $2,898.36
31297-RT Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); sphenoid sinus ostium $2,174.56*0.5 =               $1,087.28 $1,917.08 –  Base code ($197.77) =               $1,719.31
TOTAL   $4,094.72 $4,617.67

Example 3:

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

Code Description 2019 Fee  2020 Fee
31255-50 Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior) $336.24*1.5 = $504.36 $335.99*1.5 = $503.99
31267-50 Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus ($275.70*1.5)*0.5 = $206.78 $274.64 – Base code ($65.68) = $208.96
31240-RT Nasal/sinus endoscopy, surgical; with concha bullosa resection $164.34*0.5 =               $82.17 $163.12 –

Base code ($65.68) = $97.44

TOTAL   $793.31 $  810.39

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.

Code Description 2019 Fee 2020 Fee
31276-LT Nasal/sinus endoscopy, surgical, with frontal sinus exploration, including removal of tissue from frontal sinus, when performed $393.55 $391.93
31255-LT Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior) $336.24*0.5 = $168.12 $335.99 – Base code ($65.68) =

$270.31

31256-LT Nasal/sinus endoscopy, surgical, with maxillary antrostomy; $187.04*0.5 = $93.52 $186.58 – Base code ($65.68) =
$120.90
31231-XS-RT Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure) $67.03*0.5 = $33.52 $65.68
TOTAL   $688.81 $848.82

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.

Code Description 2019 Fee 2020 Fee
31298-LT Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); frontal and sphenoid sinus ostia $4,197.53 $3,685.11
31296-XS-RT Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); frontal sinus ostium $2,031.16*0.5 = $1,015.58 $1,958.58 – Base code ($197.77) = $1,892.90
31295-50 Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); maxillary sinus ostium, transnasal or via canine fossa ($2,004.86*1.5)*0.5 = $1,503.65 ($1,932.24*1.5) – Base code ($197.77) = $2,832.68
TOTAL   $6,716.76 $8,146.51

 

Barbara Cobuzzi

Barbara Cobuzzi

Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, AAPC Fellow, is a consultant with CRN Healthcare Solutions in Tinton Falls, N.J. She is consulting editor for Otolaryngology Coding Alert and has spoken, taught, and consulted widely on coding, reimbursement, compliance, and healthcare-related topics nationally. Barbara also provides litigation support as an expert witness for providers and payers.Cobuzzi is a member of the Monmouth, N.J., AAPC local chapter.
Barbara Cobuzzi

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Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, AAPC Fellow, is a consultant with CRN Healthcare Solutions in Tinton Falls, N.J. She is consulting editor for Otolaryngology Coding Alert and has spoken, taught, and consulted widely on coding, reimbursement, compliance, and healthcare-related topics nationally. Barbara also provides litigation support as an expert witness for providers and payers. Cobuzzi is a member of the Monmouth, N.J., AAPC local chapter.

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