Otolaryngology Coding Alert

Question: An otolaryngologist has to convert a Medicare patient's endoscopic maxillary antrostomy into a Caldwell-Luc procedure. May I report both operations?


Georgia Subscriber

Answer: No. Regardless of how much time the otolaryngologist spends endoscopically before making the decision to convert to open, you should bill only 31030 (Sinusotomy, maxillary [antrotomy]; radical [Caldwell-Luc] without removal of antrochoanal polyps) or 31032 (... radical [Caldwell-Luc] with removal of antrochoanal polyps). You'll probably use 31032 because otolaryngologists rarely perform the open antrotomy without removing polyps.

Medicare guidelines clearly state that when a surgeon converts an endoscopic procedure to open, you should report only the open procedure. Thus, the payer will bundle 31256 (Nasal/sinus endoscopy, surgical, with maxillary antrostomy) or 31267 (... with removal of tissue from maxillary sinus) into 31030-31032. Although CPT states that you may code both procedures with modifier -52 (Reduced services) appended to the noncompleted endoscopic procedure, most private payers follow Medicare's lead on this issue and will pay only for the open procedure.

Exception: If the endoscopic procedure plus the open procedure consumed a lot of time and effort, you can use modifier -22 (Unusual procedural services) on 31030-31032. Submit the claim on paper with a cover letter explaining the increased work.