Coding Alert

Proper coding of medical and surgical physician services is critical for accurate and efficient functioning of the fee-for-service payment system most of us operate under. Considerable effort goes into assignment and description of CPT codes used to describe physician services, which are then valued through an equally stringent process. This valuation includes delineation of the actual physician work, the expense necessary to perform this work, and a component for malpractice expense.

When codes are used inappropriately there is an adverse effect on the whole healthcare system affecting resource availability for all. The Academy has recently learned of a specific coding situation that causes us considerable concern. CPT codes 31295, 31296, 31297, and 31298 describe nasal/sinus endoscopy with dilation of a sinus ostium. This is typically, but not specifically associated with balloon dilation of sinus ostia. These codes have been defined and valued through the CPT/RUC process and payment for these codes includes the cost of the balloon kit used for dilation of the respective sinus ostia. There are other techniques of dilation that do not use balloon technology, but rather reusable fixed dilators costing considerably less than the balloons.

The Academy’s understanding is that CPT codes 31295, 31296, 31297, and 31298 for ostial dilation of the sinuses were intended to be billed when performed with a balloon. Reimbursement for these codes includes the price of a balloon kit for every two sinuses. The practice expense portion of these codes account for the vast majority of the overall payment and to accept reimbursement for the cost of the balloon kits if they were in fact not used is inconsistent with the intent and valuation of the codes. The Academy, therefore, recommends ostial dilation of the sinus ostia that does not utilize balloon technology should be coded using CPT code 31299 (unlisted procedure, accessory sinuses).