The 2011 edition of Current Procedure Terminology introduces several new codes that will likely have a major impact on the reimbursement for procedures of the paranasal sinuses.   The changes reflect the culmination of a complex process of code creation and valuation.  The impact of the changes on actual reimbursement at this time remains unclear, since local carriers for Medicare (as well as the private insurance companies) may independently develop policy statements on reimbursement for any CPT code.  Thus, practicing otorhinolaryngologists must be vigilant in adopting the new codes and applying them appropriately.

New Codes for Surgical Navigation

The 2011 edition of CPT deleted CPT +61795 (Stereotactic computer assisted volumetric (navigational) procedure, intracranial, extracranial, or spinal) and introduced three new CPT codes:

  • 61781 Stereotactic computer-assisted (navigational) procedure; cranial, intradural
  • 61782 Stereotactic computer-assisted (navigational) procedure; cranial, extradural
  • 61783 Stereotactic computer-assisted (navigational) procedure; spinal

All 3 new codes are considered add-on codes (as was CPT +61795); thus, they are not subject to the multiple procedure discount formula.

When surgical navigation is performed during routine endoscopic sinus surgery (for inflammatory conditions of the paranasal sinuses), the appropriate CPT code for surgical navigation in this instance is now CPT +61782.  Since this is still an add-on code, it should be used in addition to the codes reported for the primary procedure(s).  The American Academy of Otolaryngology policy statement on surgical navigation remains unchanged.

Although guidelines for documentation of CPT  +61782 are not firmly established yet, it seems reasonable to follow the guidelines promulgated for the old code of CPT  +61795; that is, the operative report should document the registration process, instrument calibration, review of imaging and intraoperative localization at multiple points throughout the procedure.

CPT +61781 is explicitly for intracranial/intradural surgical navigation; conceivably, endoscopic transnasal/transsinus procedures that employ surgical navigation for the intracranial portion of the surgery may be reported with this code.

The wRVUs assigned to CPT +61782 are more than 20% less than the wRVUs for CPT +61795; similarly the tRVU valuation  for CPT +61782 is more than 10% less than the tRVU for CPT +61795.

Although the codes have nonfacility valuations, payment is in general limited to procedures performed at a facility.  In addition, the rules that govern reimbursement in an ASC setting remain unchanged; that is, no reimbursement to the facility is permitted in most cases if the procedure is performed in an ASC.

Balloon Dilatation Codes

The 2011 edition of CPT introduced three new codes:

  • 31295    Nasal/sinus endoscopy, surgical; with dilation of maxillary sinus ostium (eg, balloon dilation), transnasal or via canine fossa
  • 31296    Nasal/sinus endoscopy, surgical; with dilation of frontal sinus ostium (eg, balloon dilation)
  • 31297    Nasal/sinus endoscopy, surgical; with dilation of sphenoid sinus ostium (eg, balloon dilation)

These new codes are specifically applicable with dilation is performed with no additional work done at  the specific sinus.  For procedures, where dilatation is performed and tissue is removed at the sinus ostium , the traditional codes for endoscopic sinus surgery (CPT 31254-31288) would apply.  For instance, if a surgeon performs balloon dilatation of the frontal sinus, then CPT 31296 would be reported; however, if the surgeon performed balloon dilatation of the frontal sinus ostium during dissection in the frontal recess, then CPT 31276 alone (without CPT 31296) would be reported.  Similarly, simultaneous reporting of CPT 31295 with CPT 31256 (or CPT 31267) would be inappropriate, and simultaneous reporting of CPT 31297 with CPT 31287 (or CPT 31288) would be inappropriate.

Endoscopic ethmoidectomy work is reported by the traditional codes of CPT 31254 and CPT 31255.

To put these valuations in perspective, it is important to compare them to the 2011 valuations for CPT 31231 (Nasal endoscopy, diagnostic, unilateral or bilateral), CPT 31237 (Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement), CPT 31256 (Nasal/sinus endoscopy, surgical, with maxillary antrostomy), CPT 31276 (Nasal/sinus endoscopy, surgical with frontal sinus exploration, with or without removal of tissue from frontal sinus) and CPT 31288 (Nasal/sinus endoscopy, surgical, with sphenoidotomy):

The RVU valuations reflect internally consistent valuations across the entire code family:

  • First, the malpractice RVUs for the new balloon codes are relatively small, especially in comparison to CPT 31276.  This is consistent with the published literature and anecdotal experience which both support the notion that the risk profile for CPT 31276 is much greater than balloon dilatation procedures.
  • The nonfacility valuations for CPT 31295-31297 are very high due to high practice expense RVU valuation.  The practice expense valuation for these codes is intended to cover the costs of the disposable devices.
  •  The wRVUs for CPT 31295-31297 are all lower than the wRVUs for the conventional endoscopic sinus surgery codes for the corresponding sinuses and much lower than the wRVUs for CPT 31276.  These valuations suggest greater work due to tissue dissection and removal at each sinus and especially at the frontal sinus in particular.

Conclusion

The 2011 CPT edition has introduced several new codes with practical importance for practicing otorhinolaryngologists.  These codes will allow greater specificity in coding selection and thus should facilitate more accurate coding.  Any coding change is independent from changes in payment policies.  Thus, the impact on reimbursement at this time remains unclear.

References

All RVU data and code descriptors from from 2010-2011 Code Manager.