The Centers for Medicare & Medicaid Services (CMS) has proposed changes to the payment structure for sinus endoscopy services in the 2020 Physician Fee Schedule (PFS) proposed rule (page 53). Specifically, CMS intends to apply multiple endoscopy rules, similar to those used for colonoscopies, to sinus endoscopy reimbursements. This approach is detailed in MLN Matters article MM7587, which explains the multiple endoscopy rules for colonoscopies.
Physician Impact and Rationale for Opposition
Historically, colonoscopies have been subject to multiple endoscopy payment rules, while nasal endoscopies have not. The author argues that applying the colonoscopy model to sinus endoscopies is inappropriate due to fundamental procedural differences.
- Anatomical Differences: Colonoscopies involve procedures performed along a linear structure, with each subsequent procedure progressing further. Sinus endoscopies, conversely, address distinct, non-linear sinus cavities within the head. Surgeons do not navigate through one sinus to access another.
- CPT Code 31231: The base code, CPT 31231 (Nasal endoscopy, diagnostic, unilateral or bilateral), is both a standalone procedure and bundled within all functional endoscopic sinus codes. This means it’s never separately reimbursed alongside other functional sinus endoscopies.
- 3D vs. Linear: Sinus endoscopies involve a three-dimensional relationship between procedures, considering the unilateral or bilateral nature of the interventions. This contrasts with the linear progression of colonoscopies.
The author concludes that the linear-based multiple endoscopy rules for colonoscopies are not applicable to the three-dimensional nature of sinus endoscopies.
Call to Action: Submit Comments to CMS
The author strongly encourages otolaryngologists to submit comments to CMS regarding the proposed rule. Comments must be received by 5 p.m. on September 25, 2019, to be considered for the 2020 PFS final rule.
Submission Methods:
- Electronically: Via www.regulations.gov, following the “Submit a comment” instructions.
- Regular Mail: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1715-P, P.O. Box 8016, Baltimore, MD 21244-8016.
- Express/Overnight Mail: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1715-P, Mail Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.