Endoscopic sinus surgery has become an increasingly popular treatment for chronic sinus conditions among Medicare beneficiaries over the past decade. Here's coding and billing advice for sinus procedures you might be hosting at your facility.

Diagnosis coding for ENT conditions
Let's begin with a review of common diagnosis codes:

• Concha bullosa. This is an intranasal cyst of the turbinate. There is no specific diagnosis code for this condition. Use code 478.19 (other diseases of the nasal cavity and sinuses).
• Nasal obstruction. There's no specific diagnosis code for this condition. Use code 478.19 (other diseases of the nasal cavity and sinuses).
• Deviated nasal septum. Use code 470 for septoplasty procedures.
• Hypertrophy of the nasal turbinates. Use code 478.0 for turbinate procedures.
• Sinusitis. For sinus procedures, code out each type of sinusitis problem with these codes.

Coding sinus procedures
Septoplasty procedures (code 30520) aren't bundled into sinus endoscopy procedures and are separately billable. Since septoplasty procedures are performed in the middle of the nose, they aren't billed in a bilateral manner, as are many ENT procedures. Septoplasty procedures are considered a corrective procedure done to straighten the nasal septum, which serves as a partition between the 2 nasal cavities. When the septum becomes deviated from an injury or malformation, it narrows that cavity and impedes airflow. These septal deviations can lead to nasal obstruction.

Coding turbinate procedures
Turbinates keep the nose clean by secreting mucous and providing humidity. When the turbinates become enlarged (called hypertrophy), nasal obstructions occur. The procedures ENT surgeons may perform for problems in the turbinates are resections, excisions, reductions, ablations, cauterizations, outfracturing, and endoscopic resections and/or excisions.

The various CPT codes involving turbinate procedures aren't always easily differentiated. If the otolaryngologist fails to indicate clearly what he does, there's no way for the coder to know which code to select. Precise op note terminology is crucial when billing turbinate procedures.

A standard rule of thumb with these codes: Only bill 1 turbinate procedure per turbinate per side during an operative case. Check the national Correct Coding Initiative unbundling material closely. If both sides are operated on with the same procedure, generally use a —50 modifier (except when billing Medicare) on the CPT code, unless the code descriptor states it is "unilateral or bilateral." If only one side is operated on, use an —RT or —LT modifier on the CPT code.

Excision of the inferior turbinate (partial or complete) by any method — 30130
This code was revised for 2006 to differentiate it to be used for the inferior turbinate only. Use this code when the surgeon excises mucosa and bone at the same time. This code would be used whether the procedure is performed using a scope or not.

Submucous resection of the inferior turbinate(s) (partial or complete) by any method — 30140
This code was revised for 2006 to differentiate it to be used for the inferior turbinate only. This procedure involves elevating the inferior turbinate from the turbinate bone, and making an incision into the mucosa of the inferior turbinate, so it can be excised. Precise wording in the operative report is very important in billing this procedure; the surgeon must note that he incised the mucosa and resected the turbinate bone. Use this code regardless of whether the procedure is performed using a scope. If the note just states, "Excision of inferior turbinate," you must bill the 30130 code.

Excision of or submucous resection of the superior turbinate(s) or the middle turbinate(s) — 30999
Use unlisted code 30999 when that is the only procedure performed in that area. Don't bill middle turbinectomy procedures when your surgeons perform them on the same side as a procedure on the ethmoid sinuses.

Coblation/reduction of the turbinates — 30140-52
Coblation/reduction of the turbinates is billed with code 30140-52, using the —52 modifier for reduced services, per CPT guidance.

Cauterization of the inferior turbinate mucosa (unilateral or bilateral) by any method, superficial — 30801
In this procedure, cauterization of the surface of the mucosa is performed externally or superficially only.

Cauterization of the inferior turbinate mucosa (unilateral or bilateral) by any method, deep (noted as intramural) procedure — 30802
During this more common cauterization procedure, the destruction of the mucosa takes place from within the nose. This includes radiofrequency.

A word of caution: If you perform procedures 30801 or 30802 during the same operative session with a more complex service, they might be considered unbundled and not separately billable; check the CCI material. Regardless of whether they're performed as a unilateral or bilateral procedure, however, bill these codes once with no modifiers.

Fracture (also called an "outfracture" or "infracture") of the inferior nasal turbinate(s) for therapeutic purposes — 30930
During this procedure, the surgeon improves the patency of the airway by using an instrument between the attachment of the inferior turbinate and the lateral wall of the nose, creating a fracture in that area, which lets the turbinate move laterally for the desired correction. Append bilateral procedure modifiers if this procedure is performed on both sides. CPT Assistant directs that this code is to be used for an outfracture of the inferior turbinates for airway improvement. Note that if the middle turbinate is fractured to facilitate the sinus procedure, it is considered "incidental" and is not billable.

Standard sinus endoscopy procedures
Endoscopy codes 31231 to 31297 are for unilateral procedures, unless the code description indicates otherwise, and thus should have the appropriate modifiers (—RT or —LT or —50, depending on the payor) appended to them, for proper billing. If an endoscopy procedure from this coding range is performed bilaterally, and the code descriptor doesn't indicate it is a bilateral procedure, bill the code with bilateral modifiers, as appropriate.

• Use code 31240 for the endoscopic resection of a concha bullosa (which is an intranasal cyst of the turbinate).
• Use code 31254 for an endoscopic anterior ethmoidectomy procedure.
• Use code 31255 for an endoscopic total ethmoidectomy procedure (anterior and posterior).
• Use code 31256 for an endoscopic maxillary antrostomy where no tissue is removed.
• Use code 31267 for a more extensive endoscopic maxillary antrostomy where tissue or polyps are removed.
• Use code 31276 for an endoscopic frontal sinus procedure where the surgeon may or may not remove tissue in the surgery.
• Use code 31287 for an endoscopic sphenoidotomy procedure where no tissue is removed.
• Use code 31288 for a more extensive endoscopic sphenoidotomy procedure where tissue or polyps are removed.
• If a stereotactic guidance system is used in sinus surgery procedures, use the 61782 add-on code, which is not on the Medicare ASC list.

Sinus balloon dilation endoscopy procedures
CPT added 3 new codes for these procedures for 2011:

• 31295. Maxillary sinus balloon dilation endoscopy.
• 31296. Frontal sinus balloon dilation endoscopy.
• 31297. Sphenoid sinus balloon dilation endoscopy.

CPT guidance is to not bill these codes with the standard sinus endoscopy codes for the same sinus on the same side in the same case. These new codes are covered by Medicare.

If you use irrigation with the balloon procedures, code as follows:

• 31000. Lavage by cannulation of the maxillary sinus.
• 31002. Lavage by cannulation of the sphenoid sinus.
• There is no irrigation code for the frontal sinus.

Post-op hemorrhages
For control of hemorrhage following a tonsillectomy/adenoidectomy, sinus or other ENT procedures involving the sinuses or throat, use code 31238 for a nasal/sinus endoscopy, surgical; with control of nasal hemorrhage or 42960-78 for the control oropharyngeal hemorrhage, primary or secondary (post-tonsillectomy, for example); simple for immediate post-op problems or code 42962 for the control oropharyngeal hemorrhage, primary or secondary (post-tonsillectomy, for example); with secondary surgical intervention if the procedure is performed at a later date.

The control of bleeding is always an integral part of endoscopic procedures, and is not separately billable unless the patient comes in with an active bleed before the case starts or the patient has a post-operative bleed.