31240 denying as inclusive to other endoscopy codes


Best answers
There is no CCI edit between 31240, 31255, 31267, 31276, and 31287, but I am getting denials on 31240 as inclusive. I have gotten these denials from both Anthem and Cigna. Has anyone else seen this, and is there a reimbursement policy I'm not aware of? Thanks for your help!


Local Chapter Officer
Victoria, TX
Best answers
This is a common denial since the CPT Assistant states that 31240 is bundled into 31255 IF the purpose for concha bullosa resection was to gain access to the ethmoid cavity.

CPT Assistant Archives - Nasal Turbinate Surgery is "Nothing to Sneeze At" (May 2003, pages 5-6)

It is also important to include the appropriate diagnosis for performing the turbinate procedure, such as hypertrophy with airway obstruction. If the turbinate procedure was performed to gain access to the ethmoid bone, codes 30130 and 30140 would not typically be reported, nor would 31240, Nasal/sinus endoscopy, surgical, with concha bullosa resection. However, if there is a separate diagnosis indicating medical necessity with supporting documentation, then the appropriate turbinate code (30130, 30140) may be reported by appending modifier '-59' to the code. When reporting codes 30130 and 30140, it should be noted that these codes are unilateral, since there are three turbinates in each right and left nasal cavity. cavity​

However, as stated, if there is a separate diagnosis supporting medical necessity, then you should bill 31240 with modifier -59. The AAO-HNS has a policy statement and a FAQ on this as well that you can use to support your argument. I would send these documents along with an appeal/claim letter, a corrected claim (if not originally billed with modifier 59), and a copy of the operative report. Make sure the concha bullosa resection is clearly documented as a separate procedure, independent of the total ethmoidectomy (not done for access to the ethmoid). Hope that helps!