CPT for ENT: Changes to the FESS and BSD Family of Codes for CY 2018

As AAO-HNS members are likely aware, 2018 brings significant changes to the Endoscopic Sinus Surgery (“FESS”) and Sinus Ostial Dilation (e.g., balloon sinus dilation or “BSD”) family of CPT codes. In January 2015, the FESS and BSD family of codes were captured in a CMS screen of services that are typically reported together more than 75 percent of the time.  The procedural pairings that were captured in this screen were combined frontal/total ethmoid sinus procedures, combined total ethmoid/sphenoid sinus procedures, and combined dilation of the frontal and sphenoid sinus. As a result, the FESS and BSD family of codes were required by CMS to be reviewed.

The Academy’s initial recommendation was that no action was needed due to the inherent complexities and nuances of sinus surgery.  Unfortunately, this recommendation was not accepted, and we were required to create bundled codes in line with established RUC and CMS screens.  In order to address the situation most effectively, the Academy convened a task force in June 2015, which included representatives from AAO/HNS, ARS, and AAOA. The task force worked for over a year to develop consensus recommendations that were critical to the presentation of these codes to the AMA CPT Editorial Panel and RUC in January 2016/2017.

The results of the RUC survey, which received a robust physician response, demonstrated a significant decrease in reported intra-service and total time required to complete many of the procedures in the code family. This was particularly significant in the FESS codes, which had not been surveyed since the early 1990s. The BSD codes, which had been surveyed more recently in 2011, produced data which was more consistent with the previous values, and thus their values were impacted to a far less degree.

Since release of the proposed values in July 2017, the Academy and other specialty societies have been continuously engaged in advocating to CMS for the adoption of appropriate valuation of these codes. In fact, CMS considered further reductions to many of these codes in the 2018 MPFS proposed rule. However, due to the Academy’s comments opposing these reductions (wptest.entnet.org/content/regulatory-advocacy), CMS elected to finalize the RUC-recommended values resulting from our Member surveys.

The Academy is also working with the above-mentioned task force to develop a CPT Assistant® article to assist members in better understanding the new bundled codes. Additional information on this comprehensive effort can be found in the November 2017 Bulletin article, available here.  The revised code set is outlined below.

Endoscopic Sinus Surgery

• NEW CODE: 31241 Nasal/sinus endoscopy, surgical; with ligation of sphenopalatine artery. (Do not report 31241 in conjunction with 31238, when performed on the ipsilateral side)
• 31254 Nasal/sinus endoscopy, surgical with ethmoidectomy; partial (anterior) (Do not report 31254 in conjunction with 31253, 31255, 31257, 31259, 0406T, 0407T, when performed on the ipsilateral side)
• 31255 Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior ) (Do not report 31255 in conjunction with 31253, 31254, 31257, 31259, 31276, 31287, 31288, 0406T, 0407T, when performed on the ipsilateral side)
• NEW CODE: 31253 Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including frontal sinus exploration, with removal of tissue from frontal sinus, when performed. (Do not report 31253 in conjunction with 31237, 31254, 31255, 31276, 31296, 31298, 0406T, 0407T, when performed on the ipsilateral side)
• NEW CODE: 31257 Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including sphenoidotomy. (Do not report 31257 in conjunction with 31235, 31237, 31254, 31255, 31259, 31287, 31288, 31297, 31298, 0406T, 0407T, when performed on the ipsilateral side)
• NEW CODE: 31259 Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including sphenoidotomy, with removal of tissue from the sphenoid sinus (Do not report 31259 in conjunction with 31235, 31237, 31254, 31255, 31257, 31287, 31288, 31297, 31298, 0406T, 0407T, when performed on the ipsilateral side)
• 31256 Nasal/sinus endoscopy, surgical, with maxillary antrostomy;

(For endoscopic anterior and posterior ethmoidectomy [APE] and antrostomy, with or without removal of polyp[s], use 31255 and 31256)

(For endoscopic anterior and posterior ethmoidectomy [APE], antrostomy and removal of antral mucosal disease, with or without removal of polyp[s], use 31255 and 31267)

**(For endoscopic anterior and posterior ethmoidectomy [APE], and frontal sinus exploration, with or without removal of polyp[s], use 31255 and 31276)

• 31267 Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus (Do not report 31256, 31267 in conjunction with 31295 when performed on the same sinus)

**(For endoscopic anterior and posterior ethmoidectomy [APE], and frontal sinus exploration and antrostomy, with or without removal of polyp[s], use 31255, 31256, and 31276)

**(For endoscopic anterior and posterior ethmoidectomy [APE], frontal sinus exploration, antrostomy, and removal of antral mucosal disease, with or without removal of polyp[s], use 31255, 31267, and 31276)

• 31276 Nasal/sinus endoscopy, surgical, with frontal sinus exploration, including removal of tissue from frontal sinus, when performed. (Do not report 31276 in conjunction with 31253, 31255, 31296, 31298, when performed on the ipsilateral side)

**(For endoscopic anterior and posterior ethmoidectomy and sphenoidotomy [APS], with or without removal of polyp[s], use 31255, 31287 or 31288)

**(For endoscopic anterior and posterior ethmoidectomy and sphenoidotomy [APS], and antrostomy, with or without removal of polyp[s], use 31255, 31256, and 31287 or 31288)

**(For endoscopic anterior and posterior ethmoidectomy and sphenoidotomy [APS], antrostomy and removal of antral mucosal disease, with or without removal of polyp[s], use 31255, 31267, and 31287 or 31288)

**(For endoscopic anterior and posterior ethmoidectomy and sphenoidotomy [APS], and frontal sinus exploration with or without removal of polyp[s], use 31255, 31287 or 31288, and 31276)

**(For endoscopic anterior and posterior ethmoidectomy and sphenoidotomy [APS], with or without removal of polyp[s], with frontal sinus exploration and antrostomy, use 31255, 31256, 31287 or 31288, and 31276)

(For unilateral endoscopy of 2 or more sinuses, see 31231-31235)

**(For endoscopic anterior and posterior ethmoidectomy and sphenoidotomy [APS], frontal sinus exploration, antrostomy and removal of antral mucosal disease, with or without removal of polyp[s], see 31255, 31267, 31287 or 31288 and 31276)

• 31287 Nasal/sinus endoscopy, surgical, with sphenoidotomy; (Do not report 31287 in conjunction with 31235, 31255, 31257, 31259, 31288, 31297, 31298, when performed on the ipsilateral side)
• 31288 Nasal/sinus endoscopy, surgical, with sphenoidotomy; with removal of tissue from the sphenoid sinus (Do not report 31288 in conjunction with 31235, 31255, 31257, 31259, 31287, 31297, 31298, when performed on the ipsilateral side)

Balloon Sinus Ostial Dilation

• 31295 Nasal/sinus endoscopy, surgical; with dilation of maxillary sinus ostium (e.g., balloon dilation), transnasal or via canine fossa (Do not report 31295 in conjunction with 31233, 31256, 31267, when performed on the ipsilateral side)
• 31296 Nasal/sinus endoscopy, surgical; with dilation of frontal sinus ostium (e.g., balloon dilation) (Do not report 31296 in conjunction with 31253, 31276, 31297, 31298, when performed on the ipsilateral side)
• 31297 Nasal/sinus endoscopy, surgical; with dilation of sphenoid sinus ostium (eg, balloon dilation) (Do not report 31297 in conjunction with 31235, 31257, 31259, 31287, 31288, 31296, 31298, when performed on the ipsilateral side)
• NEW CODE: 31298 Nasal/sinus endoscopy, surgical; with dilation of frontal and sphenoid sinus ostia (e.g., balloon dilation) (Do not report 31298 in conjunction with 31235, 31237, 31253, 31257, 31259, 31276, 31287, 31288, 31296, 31297, when performed on the ipsilateral side)

The primary changes are as follows:

1. Sphenopalatine artery (SPA) ligation has its own dedicated code: 31241.  This code should only be used for endoscopic SPA ligation, and not for any other procedure used to control epistaxis.  All other endoscopic procedures used to control epistaxis will continue to be reported with 31238, and any work to control hemorrhage associated with the performance of FESS remains bundled with the primary procedure.
2. When doing both a frontal sinus exploration (with or without tissue removal) combined with a total ethmoidectomy on the same side, use 31253.  If only a partial anterior ethmoidectomy is performed, then the two procedures are still separately reported with 31254 and 31276.
3. Similarly, when performing both a sphenoid sinus procedure and total ethmoidectomy on the same side, use either 31257 or 31259 depending on whether or not tissue was removed from the sphenoid sinus.
4. When performing both a frontal and sphenoid sinus ostial dilation the same side, use code 31298.

It is worth noting that if a frontal sinus exploration is performed on the same side and at the same time as a total ethmoidectomy and sphenoid sinus exploration, then this could be reported with either 31253 with 31287 or 31288 (depending on whether or not tissue was removed from the sphenoid sinus); or with 31276 and then the appropriate combined sphenoid/total ethmoid code (31257 or 31259 depending on whether or not tissue was removed from the sphenoid sinus.)  Which code pairing to use would most likely be determined by payer policy and how multiple procedure discounts are handled by each payer.

**It is also worth noting that the parentheticals after 31256, 31267, and 31276 are incorrect and were missed during the editing process of CPT 2018.  They still instruct surgeons to use 31255 and 31276, 31287, and/or 31288 for combined total ethmoidectomy with frontal or sphenoid sinus work.  This is incorrect and the failure to remove these parentheticals was simply an editorial oversight that is being addressed.

Lastly, there are also several changes to the introductory language for the sinus endoscopy section.  The two most significant changes are:

1. The introductory language specifically indicates that 61782 is meant to be used as an add-on code with FESS when image guidance is used.  The AAO/HNS has a position statement on when image guidance is clinically indicated, and this statement can be found here.
2. The section spells out in more detail the anatomic structures that must be visualized when performing a nasal endoscopy and provides guidance on how to report the service when all of the structures cannot be seen.  Modifier -52 Reduced Services should be appended when all structures cannot be seen and no repeat exam is planned, and modifier -53 Discontinued Procedure is to be used when repeat endoscopy to visualize these structures is expected/planned. Refer to the full description of these modifiers in CPT 2018 for more information. NOTE: This change was not requested by the AAO/HNS but was mandated by the CPT Editorial Panel in response to the Task Force’s request to allow reporting of a full nasal endoscopy even when anatomic considerations (such as a deviated septum or mass lesion) prevent full visualization of the required elements).

Reviewed October 2023
Published January 2018

IMPORTANT DISCLAIMER NOTICE
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.