In late 2006, there was a proposal from CMS and NCCI to remove the modifier over-ride of CPT code 31231 –Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure) when billed with the flexible fiberoptic laryngoscopy CPT codes (31575-31578). The CMS and NCCI staffs rationale was CPT code 31231 was inclusive in the flexible fiberoptic laryngoscopy CPT codes. The Academy argued to maintain the edits, which would allow separate reimbursement for each code when another endoscope was necessary to perform the nasal/sinus endoscopy and the laryngoscopic exam. The Academy provided several clinical examples illustrating situations where flexible laryngoscopes could not visualize intranasal or intrasinus structures due to anatomic constraints typically, when separate diagnoses were present.
Early in 2008, the Academy readdressed the proposed edits above with NCCI and CMS. Both of these agencies rendered a final decision in February 2008 to maintain the ability to over-ride the edits with a -59 (distinct procedural service) modifier for CPT code 31231. Report this CPT code and modifier combination infrequently, and the surgeon’s medical records should provide clear documentation explaining the necessity of using two different endoscopes on the same date of service. To quote from NCCI:
“CMS will not modify the modifier indicators for these edits continuing to allow use of NCCI-associated modifiers. A provider should NOT report both codes of a code pair edit if the nasal endoscopy can be performed with the same flexible endoscope utilized for the laryngoscopy. However, we understand that there are very occasional circumstances where it is medically reasonable and necessary for a provider to perform the nasal endoscopy with a separate rigid endoscope. In the latter scenario, a provider may report both codes of a code pair edit utilizing an NCCI-associated modifier.”
Approved July 2008
Reviewed April 2009
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.