CPT for ENT: Coding 31000 with Balloon Dilation Procedures

CPT for ENT: Coding 31000 with Balloon Dilation Procedures

CPT for ENT: Coding 31000 with Balloon Dilation Procedures

Q: I’ve noticed that there are not any coding edits in place for CPT 31000 Lavage by cannulation; maxillary sinus (antrum puncture or natural ostium) when billed with 31295 (endoscopic balloon dilation of the maxillary sinus). Does this mean I can code separately for the work of lavage when performing this service?

A: No. The lavage is a lower-valued procedure performed at the same operative session on the same structure (maxillary sinus) and, therefore, would be included in the primary procedure code of 31295. Some additional things to consider are:

  • •The vignette associated with 31295 includes a statement that a catheter for irrigation may be placed at the same time. This unequivocally means that irrigation of the dilated sinus INCLUDES irrigation if performed at the same session.
  • The only time 31000 should be reported with 31295 is if the primary procedure is performed on one side and ONLY an irrigation is performed on the opposite, contralateral side. In this case, the procedures would be reported using RT and LT modifiers. A -59 modifier would not be used, as there is not currently a CCI edit in place for this code combination.
  • 31000 is an open code [i.e. anterior rhinoscopic guided service] and 31295 is an endoscopic code.
  • 31000 represents a separate procedure in which the nose is anesthetized, decongested and a needle or cannula inserted into the antrum for irrigation. It is not intended for flushing through a patent or newly created surgical opening into the antrum
  • The same logic would apply to 31002 with relevant sphenoid codes.

Q: In addition, there is a CCI edit in place of "1" for the code combinations of 31000 with 31256 (endoscopic maxillary antrostomy) and 31267 (endoscopic maxillary antrostomy with tissue removal from within the sinus), but I am able to bypass the edit using modifier 59 (distinct procedural service). Is it appropriate to append modifier 59 to 31000 in these instances?

A: No, it is not appropriate to append modifier 59 to 31000 just to get the procedure paid. You must meet the criteria for use of modifier 59 in order to use the modifier appropriately and bypass the CCI edits. The lavage is a lower-valued procedure performed at the same operative session on the same structure (maxillary sinus) and, therefore, would be included in the primary procedure codes of 31256, 31267. Some additional things to consider are:

  • •The only time 31000 should be reported with 31256, 31267 with a 59 modifier is if the primary procedure is performed on one side and ONLY an irrigation is performed on the opposite, contralateral side.
  • •31000 is an open code [i.e. anterior rhinoscopic guided service] and 31256, 31267 are all endoscopic codes.
  • •31000 represents a separate procedure in which the nose is anesthetized, decongested and a needle or cannula inserted into the antrum for irrigation. It is not intended for flushing through a patent or newly created surgical opening into the antrum.
  • •Overuse of the -59 modifier with certain code combinations can trigger a CMS review of the code combination that could alter our ability to bill separately for these codes in the future.
  • •The same logic would apply to 31002 with relevant sphenoid codes.

Approved August 2013

Important Disclaimer Notice (Updated 8/7/14)

CPT for ENT articles are a collaborative effort between the Academy’s team of CPT Advisors, members of the Physician Payment Policy (3P) workgroup, and health policy staff. Articles are developed to address common coding questions received by the health policy team, as well as to clarify coding changes and correct coding principles for frequently reported ENT procedures. These articles are not intended as legal, medical, or business advice and are not a guarantee of reimbursement. The information is also not meant to serve as the definitive or sole authority on billing and coding issues. The applicability of AAO-HNS billing and coding guidance for a particular procedure, must be determined by the responsible physician in light of all the circumstances presented by the individual patient. You should consult with your own advisors as well as Medicare or private carriers in making any decisions about how to bill and code particular services or procedures.