Maxillary Sinus Lavage (31000)

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Question:  

My doctors want to bill 31000 for a maxillary sinus lavage every time they do an endoscopic procedure on the maxillary sinus such as 31256 (endoscopic maxillary antrostomy), 31267 (endoscopic maxillary antrostomy with tissue removal from within the sinus) and 31295 (endoscopic balloon dilation of the maxillary sinus). The lavage is bundled with 31256 and 31267 when I look at Medicare’s Correct Coding Initiative edits but I can bypass the edit using modifier 59 (distinct procedural service). Is it appropriate for us to append modifier 59 to 31000 in these instances? CPT 31000 is not bundled with the balloon dilation code, 31295, so it must be ok to bill both codes.

Answer:

It is not appropriate to append modifier 59 to 31000 just to get the procedure paid. You must meet the criteria for use of modifier 59 in order to use the modifier appropriately and bypass the CCI edits. In these three examples, it is not accurate to separately report 31000 with or without a 59 modifier. The lavage is a lower-valued procedure performed at the same operative session on the same structure (maxillary sinus) and, therefore, would be included in the primary procedure codes of 31256, 31267 or 31295. Do not separately report 31000 for maxillary sinus lavage.