ENT practices often encounter unique billing challenges. These may range from accurately coding specialized diagnostic procedures to understanding modifier usage for various anatomical exams. These intricacies make it integral to pay attention to the details while billing for procedures, such as nasal endoscopies (CPT code 31231).
Failure to follow the billing and reimbursement guidelines set forth by payers and federal and state bodies may result in adverse consequences. Costly claims denials and payment delays are just a few that can significantly impact your practice’s revenue cycle.
This guide offers comprehensive insights into CPT code 31231. Thus, if you want to equip your team with the tools to conquer common billing challenges related to this procedure, this guide is exclusively for you!
So, without further ado, let’s get started!
CPT Code 31231 – Description
CPT code 31231 is from the ‘Endoscopy Procedures on the Accessory Sinuses’ code range. Similar to all CPT code ranges, the American Medical Association (AMA) maintains this code range.
It covers the diagnostic nasal endoscopy procedure. The healthcare provider performs it by inserting an endoscope into the nasal cavity. This procedure aims to examine the structures of the nasal cavity on one or both sides.
Scenarios Where CPT Code 31231 is Applicable
Here, let’s take a look at some real-world clinical scenarios where CPT code 31231 applies:
Recurrent Epistaxis Investigation
Picture a 51-year-old male patient who visits an ENT clinic. He complains of experiencing unexplained, recurrent epistaxis (nosebleeds) from the right nostril. The bleeding does not easily stop with pressure.
Therefore, the otolaryngologist performs a diagnostic nasal endoscopy (CPT code 31231) of the right nasal cavity. The procedure helps the provider locate the precise source of the bleeding and rule out any underlying masses or polyps.
Chronic Rhinosinusitis Evaluation
Consider a 32-year-old female patient who visits the otolaryngologist. She has been experiencing persistent nasal congestion, facial pressure, and thick post-nasal drip for the past few months. Previously, the physician prescribed her nasal steroid sprays and antibiotics, but the treatment plan failed to improve the symptoms.
Thus, the otolaryngologist performs a diagnostic nasal endoscopy (CPT code 31231). It enables visualization of the nasal and sinus drainage pathways and identifies any polyps, inflammation, or structural abnormalities.
Unexplained Anosmia/Hyposmia Assessment
Imagine a 47-year-old male patient with a persistent and significant loss of sense of smell (symptoms consistent with hyposmia or anosmia). The condition developed over several months without a clear cause.
As a result, the otolaryngologist performs a diagnostic nasal endoscopy (CPT code 31231). It helps rule out any nasal polyps, severe inflammation, or other anatomical obstructions that impact the olfactory region.
Applicable Modifiers for CPT Code 31231
Discussed below are all applicable modifiers for the diagnostic nasal endoscopy covered under CPT code 31231:
Modifier 52
When a nasal endoscopy is reduced in scope at a physician’s discretion, report modifier 52 to CPT code 31231 to ensure fair reimbursement.
Modifier 58
Append modifier 58 to CPT code 31231 when the sinus endoscopy is a postoperative planned or anticipated procedure following an initial nasal or sinus surgery with a global period.
It also applies when the endoscopy is for therapy following a diagnostic surgical procedure or when it is more extensive than the original service.
However, note that your documentation must support the staged relationship of services.
Modifier 59 and XS
You cannot report CPT code 31231 with more extensive nasal endoscopies unless the physician performs these on different structures. However, you should append modifier 59 or XS under the multiple endoscopy rule.
For context, the multiple endoscopy rule offers guidance on reimbursement when a provider performs two or more endoscopies on the same patient in the same family. Under this rule, the highest-valued endoscopy is typically reimbursed at 100%, while subsequent endoscopies in the same family receive a reduced payment.
Modifier 78
What happens when the postoperative sinus endoscopy requires an unplanned return to the operating room? You append modifier 78 to CPT code 31231 to indicate it is related to the initial surgical procedure.
However, you cannot report modifier 78 when the physician performs endoscopy in an office setting (POS 11). In office settings, if the endoscopy is staged, applying modifier 58 will be more appropriate.
CPT Code 31231 – Billing & Reimbursement Guidelines
The following are some essential requirements and guidelines to ensure accurate reporting of CPT code 31231:
Report CPT 31231 for ‘Bilateral’ & Unilateral Service
The CPT 31231 descriptor covers nasal endoscopy on one (unilateral) or both (bilateral) sides of the nasal cavity. Therefore, you can report it as it is without appending laterality modifiers, such as LT, RT, or 50.
Ensure Detailed Documentation & Medical Necessity
Reimbursement against the CPT code 31231 requires comprehensive documentation that supports medical necessity. Therefore, you should strive to include clear medical indications for performing the diagnostic nasal endoscopy. These may include, but are not limited to, postoperative assessment, cerebrospinal fluid (CSF) leak, and recurrent nosebleeds.
Additionally, you should provide a comprehensive report with the medical claim detailing the following:
- The reason behind performing nasal endoscopy, e.g., patient symptoms.
- The scope of endoscopy examination. That is, whether the physician examined both nasal cavities or a single one. If the provider performs a unilateral nasal endoscopy, clearly mention the side (right or left).
- Findings of the endoscopy examination, e.g., inflammation, bleeding sites, anatomical variations, presence/absence of polyps, etc.
- Other procedures performed with the endoscopy. For instance, minor incidental debridement.
Use Appropriate Modifiers
Coding specificity is another key requirement. It ensures fair reimbursement and prevents audits. Therefore, when billing for nasal endoscopy, do not forget to include the relevant modifiers. Some of the modifiers that apply to CPT 31231 are 52, 58, 59, 78, and XS.
We have discussed in detail the appropriate usage of these modifiers in the ‘Applicable Modifiers for CPT Code 31231’ section to help you avoid the misuse and overuse of modifiers.
Summary
We have covered a lot of ground in this comprehensive guide, from applicable modifiers to essential billing guidelines. Thus, as we wrap things up, let’s quickly review the key takeaways that will help you excel at billing nasal endoscopies.
First, we explained the CPT code 31231 descriptor. It covers the diagnostic nasal endoscopy (unilateral or bilateral).
We also shared a few real-world clinical scenarios where CPT 31231 applies. These include investigation of unexplained anosmia/hyposmia, chronic rhinosinusitis, and recurrent epistaxis.
Next, we shared a list of all applicable modifiers related to diagnostic nasal endoscopy procedures, including 52, 58, 59, XS, and 78. Finally, we discussed the essential billing guidelines for accurately reporting the diagnostic nasal endoscopy.
Hopefully, these details will help you overcome the endoscopy-related billing struggles. However, if you need professional assistance, partner with MediBillMD for tailored ENT billing services.
