What Does the 2020 MPFS Say About Nasal/Sinus Endoscopy Payment?

Medicare payment for nasal and sinus endoscopy

The 2020 Medicare Physician Fee Schedule (MPFS) final rule states Medicare will apply the special rule for multiple endoscopic procedures to nasal/sinus endoscopy medical codes 31231-31298. In case you don’t have time to wade through the whole long rule, here are the major pointers on this change for otolaryngology coders. The change will be effective Jan. 1, 2020, for Medicare claims.

Learn Multiple-Scope Base and Family Codes

The 2020 MPFS final rule makes diagnostic code 31231 (Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure)) the base procedure for the other nasal/sinus endoscopies, 31233-31298. If you report a code from 31233-31298 with the base procedure code 31231, Medicare will not pay separately for 31231.

As you can see in 31231’s descriptor, it is defined as a “separate procedure.” That means that in the past, you also have not been able to report 31231 unless it was performed alone or was unrelated to other procedures carried out at the same time. (But some coders want clarity on whether Medicare will allow reporting 31231 for one side of the nose and another code from the family on the other side of the nose, as a comment below will show.)

Comment: Will Bilateral Adjustment Happen First?

The MPFS final rule includes a summary of comments with responses. One commenter asked whether the bilateral payment adjustment would apply before other forms of multiple procedure rules. Medicare did not provide a clear answer in the final rule, directing the commenter to the 1992 MPFS rule (56 Federal Register 59515) where the multiple endoscopy policy was established, and to Medicare Claims Processing Manual, Chapter 23.

But it’s worth noting that codes 31233-31298 have bilateral indicator “1” on the MPFS (2019). The definition for this indicator states, “apply the bilateral adjustment before applying any applicable multiple procedure rules.” The bilateral adjustment for this indicator is 150 percent.

Soon-to-be base code 31231 has a bilateral indicator of 2 in 2019, meaning it’s priced as a bilateral procedure. Consequently, you don’t get additional payment for reporting the service using modifier 50 (Bilateral procedure) or some other coding means of showing the service was bilateral.

Indicator definitions are available in Medicare Claims Processing Manual, Chapter 23.

Comment: Does Side Matter for the Multiple Scope Rule?

Another commenter asked about what happens when the procedures are performed on different sides of the nose. Specifically, would the new rule allow you to report base code 31231 for one side of the nose in addition to codes from the family for the other side of the nose? The MPFS does not provide an answer, instead saying to contact your local Medicare Administrative Contractor (MAC) for information on how to use 31231.

The MPFS does not name the commenter, but it’s possible this was from the American Academy of Otolaryngology-Head and Neck Surgery’s comment letter, which includes similar wording.

Comment: What Will the Multiple Procedure Indicator Be?

The next comment related to the multiple procedure indicator these codes will have on the 2020 MPFS. Medicare indicated that other than base code 31231, the codes will have multiple procedure indicator “3,” which is defined here:

3: Special rules for multiple endoscopic procedures apply if procedure is billed with another endoscopy in the same family (i.e., another endoscopy that has the same base procedure). The base procedure for each code with this indicator is identified in the endoscopic base code field. Apply the multiple endoscopy rules to a family before ranking the family with other procedures performed on the same day (for example, if multiple endoscopies in the same family are reported on the same day as endoscopies in another family or on the same day as a non-endoscopic procedure). If an endoscopic procedure is reported with only its base procedure, do not pay separately for the base procedure. Payment for the base procedure is included in the payment for the other endoscopy.

In short, with the multiple scope rule, you get full reimbursement for the highest valued procedure and then get paid based on the difference between the next highest code from the same family and the base code. Medicare Claims Processing Manual, Chapter 12, Section 40.6.C.13, includes an example based on colonoscopy services that you may find helpful if you’re new to the rule.

Multiple procedure indicator “3” will be a change for the nasal/sinus codes because in the fourth quarter 2019 MPFS, they have multiple procedure indicator “2”:

2: Standard payment adjustment rules for multiple procedures apply. If the procedure is reported on the same day as another procedure with an indicator of 1, 2, or 3, rank the procedures by fee schedule amount and apply the appropriate reduction to this code (100 percent, 50 percent, 50 percent, 50 percent, 50 percent, and by report). Base payment on the lower of: (a) the actual charge or (b) the fee schedule amount reduced by the appropriate percentage.

To help understand the impact of this payment policy change, it also helps to know that the total relative value units (RVUs) for the codes will stay roughly the same between the fourth quarter of 2019 and the first quarter of 2020. Some RVUs will go up and some will go down. For instance, for non-facility services, 31231 will drop from 5.69 total RVUs in 2019 to 5.48 in 2020. But 31254 (Nasal/sinus endoscopy, surgical with ethmoidectomy; partial (anterior)) will increase from 11.78 to 11.99. Remember that to get the national Medicare rate, you multiply the RVUs by the conversion factor, which will see a slight increase in 2020 to 36.0896 from 2019’s 36.0391. The final fee will then be adjusted based on additional factors, such as geographic location.

Comment: Is This Change Really Appropriate for Nasal Endoscopy?

A final commenter stated that the multiple scope rule should not apply to nasal/sinus endoscopies because they differ significantly from colonoscopy procedures, which also have the rule applied. The commenter also opposed application of the rules in the non-facility setting in particular. Medicare disagreed with the commenter.

The end result is that Medicare will start applying the special rules for multiple endoscopic procedures to these nasal/sinus endoscopy codes in 2020. As a last tip to be sure your nasal/sinus coding is ready for 2020, remember that 31233-31235 and 31292-31298 will see minor descriptor adjustments in the CPT® 2020 code set, arranging them more formally into groups.

What About You?

Are you an otolaryngology coder? Do you agree with this change to nasal and sinus endoscopy payment? Do you think the anatomy of these services was properly considered in making these rules?


Deborah works on a wide range of TCI SuperCoder projects, researching and writing about coding, as well as assisting with data updates and tool development for our online coding solutions. Since joining TCI in 2004, she’s covered the ins and outs of coding for radiology, cardiology, oncology and hematology, orthopedics, audiology, and more.

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