Otolaryngology Coding Alert

Hint: The more you know details, the easier your coding will be.  

Endoscopic sinus surgeries can be some of the most common procedures your otolaryngologist performs, which means you need to be confident in your coding – and in checking your surgeon’s documentation. Our experts recommend keeping eight factors in mind to smooth the claims process. 

Code choices: CPT® includes several codes for endoscopic sinus surgery, differentiated by the procedure’s complexity and the sinuses treated. The most common options include: 

• 31254 – Nasal/sinus endoscopy, surgical, with ethmoidectomy, partial (anterior) 

• 31255 – Nasal/sinus endoscopy, surgical, with ethmoidectomy, total (anterior and posterior) 

• 31256 – Nasal/sinus endoscopy, surgical, with maxillary antrostomy

• 31267 – Nasal/sinus endoscopy, surgical, with maxillary antrostomy with removal of tissue from maxillary sinus

• 31276 – Nasal/sinus endoscopy, surgical, with frontal sinus exploration, with or without removal of tissue from frontal sinus

• 31287 – Nasal/sinus endoscopy, surgical, with sphenoidotomy

• 31288 – Nasal/sinus endoscopy, surgical, with sphenoidotomy with removal of tissue from the sphenoid sinus. 

The challenges: “Code 31267 is reported incorrectly when 31256 should be coded,” says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J. “In order to report 31267, the doctor must document and remove tissue that is more than just mucous – it has to be a polyp or fungal ball or some form of mucosa (tissue). It does not include the tissue that’s removed to open the maxillary sinus, which makes the antrostomy. That’s part of 31256. The same applies to 31287 and 31288 for the sphenoid sinuses.” 

Another detail: Cobuzzi adds that for 31276, the surgeon must go into the frontal sinuses – something beyond an exploration. “Even though the code says ‘exploration,’ just looking into the frontal sinuses is not enough to qualify for 31276,” she explains. “You need to get into the frontal sinuses, take out bone, and open up the frontal sinus opening.” 

Know What’s Included in Each Code

The most important factor when coding endoscopic surgery is to understand exactly what each code represents and whether the descriptor includes the work of another code. A good starting point is to remember the following examples.  

• Every surgical sinus code includes a diagnostic endoscopy, so the diagnostic test is not separately reportable with codes 31231 (Nasal endoscopy, diagnostic, unilateral or bilateral [separate procedure]), 31233 (Nasal/sinus endoscopy, diagnostic with maxillary sinusoscopy [via inferior meatus or canine fossa puncture]), or 31235 (Nasal/sinus endoscopy, diagnostic with sphenoid sinusoscopy [via puncture of sphenoidal face or cannulation of ostium]). 

• All surgical sinusotomy codes include nasal polypectomy (31237, Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement [separate procedure]). That’s because the otolaryngologist must remove whatever is in the patient’s nose in order to access the sinuses. 

• Similarly, the work of a frontal sinusotomy includes anterior ethmoidectomy (31254) because the surgeon must go through the anterior ethmoid cell to reach the frontal sinus. You can, however, bill a posterior or total ethmoidectomy separately with 31276 when performed with the frontal sinusotomy. 

• The middle turbinates are on the lateral part of each side of the nose. Middle turbinate surgery is included in endoscopic sinus surgeries and not separately reportable. The only exception is that you can separately report an endoscopic resection of a concha bullosa (an air-filled pocket in the middle turbinate). When coding for this scenario, you’ll want to submit the appropriate concha bullosa procedure code with 31240 (Nasal/sinus endoscopy, surgical; with concha bullosa resection).

• Report one code for each sinus on each side that work is performed, even if the surgeon performed more than one procedure on the sinus because of the overlap in the definition. For example, the otolaryngologist might complete a maxillary antrostomy and remove tissue from within the maxillary sinus. You’ll only submit 31267, not 31267 and 31256. That is because 31267 includes 31256 in the definition of 31267.

Verify Medical Necessity

“When we do endoscopic sinus surgery, medical necessity documentation to avoid denials is a must,” says Catherine Tinkey, administrator for ENT Medical Services, PC, in Iowa City. “I would suggest always checking with the patient’s specific insurance plan to see if there are any guidelines in place, such as the patient has to have had three or more sinus infections in a 12 month period, the patient has to have used a steroid nasal spray for three or more months with no improvement, etc.” 

Patients typically should have followed a series of medical therapies with no significant signs of improvement before undergoing sinus surgery. Examples of conditions that can help justify medical necessity include: 

• Nasal polyps or mucoceles 

• Chronic sinusitis 

• Tumors of the nasal and/or sinus cavities 

• Recurrent sinus infections or complications of sinusitis.

Encourage Clean, Detailed Documentation

As with any procedure your providers perform, your coding choices for endoscopic surgery – and reimbursement success – hinge on documentation. Train your surgeons to include three important facts in every endoscopic surgery chart: 

• Notes regarding whether the surgeon performed the procedure on one side or bilaterally. 

• Documentation that the surgeon used an endoscope. That single detail points you toward the endoscopic sinus codes listed above instead of an open sinusotomy codes (31020-31081). Reimbursement for endoscopic procedures can be as much as a half to a third of open sinusotomy codes. But endoscopic services have zero global days while open sinusotomy codes carry 90 global days. You can charge for every service post operative after endoscopic sinus surgery while your surgeon must provide 90 days of no charge post operative care when an open procedure is performed.  

• Specifics regarding tissue removed from the sinuses, before you can submit 31267 and/or 31288. “Tissue” refers to polyps, a mucocele, or a fungus ball – not simply debris or pus. If the surgeon removed tissue from the opening of a sinus, that’s not the same as from within the sinus, so should not be reported with 31267 or 31288. 

Bilateral note: Always verify how a payer wants to you report bilateral procedures before you submit the claim. Medicare wants you to report the procedure on a single line as a single unit with modifier 50 (Bilateral procedure) and expects you to double your fee. Medicare will pay the physician 150% of the allowable fee for bilateral services.  Keep in mind that the 150% will be cut in half if it is a multiple procedure (not the primary, highest RVU procedure).  Many other payers, however, want you to submit each procedure code on a separate line with modifiers LT (Left side) and RT (Right side) to illustrate bilaterality. 

“The documentation should state when the physician moves from one area to the other,” Tinkey says. Examples might include “attention was then turned to the left maxillary portion of the endoscopic portion of the procedure” or “next the endoscope was turned to the right sphenoidectomy.”