CMS Proposes Payment Changes to Endoscopic Sinus Codes

CMS Proposes Payment Changes to Endoscopic Sinus Codes

The Centers for Medicare & Medicaid Services (CMS) is proposing major payment changes to sinus endoscopy services. The 2020 Physician Fee Schedule (PFS) proposed rule includes the following excerpt:

We are proposing to apply the special rule for multiple endoscopic procedures to this family of codes beginning in CY 2020. This proposal would treat this group of CPT codes consistently with other similar endoscopic procedures when codes within the CPT code family are billed together with another endoscopy service in the same family. Similar to other similar endoscopic procedure code families, we are proposing that CPT code 31231 (Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure)) would be the base procedure for the remainder of nasal sinus endoscopies.

What Does This Mean for Physicians?

This means CMS is looking to apply the multiple endoscopy rules, as are found with colonoscopy codes, when reimbursing for sinus endoscopy services. (You can find more information as to how the multiple endoscopy rules are handled when determining the reimbursement for colonoscopies in MLN Matters article MM7587.)

Form an Opinion

All these years, while colonoscopies have had the family of scopes and multiple endoscopy rules for payment, nasal endoscopies have not, and it always felt right to me. To comment on CMS’ PFS proposed rule, I had to think why it was appropriate for colonoscopies and not for nasal endoscopies. My reasoning is below:

Nasal endoscopies are different in nature from colonoscopies. The base scope and multiple endoscopies for the colonoscopies is based on scopes performed on a long, linear-like structure, with each different procedure going further into the linear structure and/or removing polyps by different methods.

The sinus endoscopies are not progressively performed on linear structures — they are performed on different parts of the head; and the surgeon does not go through one sinus to get to another sinus. Going through a structure, such as a middle turbinate, is bundled into the nasal endoscopy. Although sinus endoscopies are on a family of sinuses and are scopes, they do not equate to the family of colonoscopies which are linear in nature.

Additionally, the base scope indicated in the proposed rule, CPT 31231 Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure), is both a separate procedure and bundled in all other functional nasal endoscopy codes. This means that the diagnostic nasal endoscopy is never paid with any other functional nasal endoscopies.

And, finally, nasal endoscopies are performed on one or both sides of the head. Not only is there not a linear relationship, but there is a 3D relationship between any and all nasal endoscopies being performed. As a result, one can conclude that the same rules, pricing nasal endoscopies like colonoscopies, should not be applied.

Tell CMS What You Think

It is important for as many otolaryngologists to comment on the proposed fee schedule as possible. Send comments on the proposed rule for the 2020 PFS via:

  1. Electronically. Go to www.regulations.gov and follow the “Submit a comment” instructions.
  2. By regular mail. Mail written comments to: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1715-P, P.O. Box 8016, Baltimore, MD 21244-8016.
  3. By express or overnight mail. Send written comments to: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1715-P, Mail Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.

Comments must be received by CMS no later than 5 p.m. on Sept. 25, 2019, to be considered in the 2020 PFS final rule.

Certified ENT Coder CENTC


Note: The opinion of this writer is not an official AAPC endorsement.

Barbara Cobuzzi

Barbara Cobuzzi

Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, AAPC Fellow, is a consultant with CRN Healthcare Solutions in Tinton Falls, N.J. She is consulting editor for Otolaryngology Coding Alert and has spoken, taught, and consulted widely on coding, reimbursement, compliance, and healthcare-related topics nationally. Barbara also provides litigation support as an expert witness for providers and payers.Cobuzzi is a member of the Monmouth, N.J., AAPC local chapter.

Barbara Cobuzzi

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