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balloon codes 31296

  1. #1
    Default balloon codes 31296
    Medical Coding Books
    Is anyone getting paid for this balloon code? We have been told by the representative if tissue is taken use the other sinus codes and forfeit the balloon code. If only the balloon is used then use the balloon code. The balloon code has HUGE RVU's attached to it. Our physician is asking me to post for feedback.

    Thank You

  2. #2
    Default Balloon Codes
    One of our ENT doctors just started providing balloon sinuplasty's in office and after having tracked the first 4 they have all paid. The representative is correct in that if you remove tissue from the frontal sinus you would revert back to the regular FESS cpt and not bill the balloon. You should only be billing the balloon for the sinus used in, if no tissue is removed.

    For example, if your physician does a standard maxillary antrostomy with removal of tissue 31267 (you could not use 31295-balloon sinuplasty of maxillary sinus) but then the physician performs (at the same session) a balloon sinuplasty of frontal sinus with no removal of tissue you would be able to bill 31296 with 31267.

    Hope this helps
    A.Dimmitt, CPC, CIRCC
    Durham, North Carolina

  3. #3
    Location
    Jacksonville/Jacksonville Beach
    Posts
    15
    Default
    I know this is a little late, but confirmation of site of service makes a big difference in the allowables with some insurances. For instance, Cigna defaults to the facility based RVU's unless you specifically contact them to request non-facility RVU calculations for doing them in the office.

  4. Default Balloon sinuplasty
    I have been billing these codes for a very long time, BCBS of TX, NM, IL and OK absolutely refuse to pay the codes of 31295, 31296, and 31297, I have to revert to the old codes no matter if balloon is used or not, they are still considered experimental. My physician as started performing these procedures in the office instead of the OR for Aetna, Medicare and United Healthcare and getting wonderful reimbursement, very high in fact, which we verify at the time of verification of benefits; we always tell the insurance company it will be a place of service in the office to get the higher reimbursement. This didn't work with Cigna, however, they did tell us it would be ok to perform the surgery in the office, but they didn't tell us they don't differentiate RVU's between place of services. If it is outpatient, its a set reimbursement. I have gone around and around with them and finally got a one time deal for the only Cigna procedure we have done, but they will not absolutely change our contract regarding these codes or place of service. They said contracts are area wide and they do not make exceptions to contract, so I would be very interested if anyone knows different, then I will keep plugging along to get this changed.

  5. #5
    Default Balloon Sinuplast reimbursement
    Quote Originally Posted by Thouvenel View Post
    I have been billing these codes for a very long time, BCBS of TX, NM, IL and OK absolutely refuse to pay the codes of 31295, 31296, and 31297, I have to revert to the old codes no matter if balloon is used or not, they are still considered experimental. My physician as started performing these procedures in the office instead of the OR for Aetna, Medicare and United Healthcare and getting wonderful reimbursement, very high in fact, which we verify at the time of verification of benefits; we always tell the insurance company it will be a place of service in the office to get the higher reimbursement. This didn't work with Cigna, however, they did tell us it would be ok to perform the surgery in the office, but they didn't tell us they don't differentiate RVU's between place of services. If it is outpatient, its a set reimbursement. I have gone around and around with them and finally got a one time deal for the only Cigna procedure we have done, but they will not absolutely change our contract regarding these codes or place of service. They said contracts are area wide and they do not make exceptions to contract, so I would be very interested if anyone knows different, then I will keep plugging along to get this changed.
    This is right, we were also denied by BCBS of TX considering 31295, 31296 and 31297 as experimental. In this case pt can file a claim with state insurance commissioner. We are still waiting on that so don't know the results. With Cigna, I contacted the contracting network management dept, and they helped my Physician to update the contract for special procedures done on office which do reimburse more then in OR setting.

    We are getting hard time with Aetna. We billed 31296, 31296/50, 31297 and 31297/50 to Aetna for Physician. Aetna is paying 100% of allowed amt for 31296, 50% of allowed amt for 31297, and 25% of allowed amt for 31297 & 31297/50. Even appeal is denied. My Physician do not want to except 50% and 25% payments. Any one has any tip on how to deal with Aetna to get 100% paid for all procedures done in office setting?

    Thanks

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