Clinical Consensus Statement: Balloon Dilation of the Eustachian Tube (BDET), published by the American Academy of Otolaryngology  ̶  Head and Neck Surgery, June 4, is important because BDET is newer technology and may be rejected for payment by third-party payers as “experimental” or “investigational.” The American Academy of Otolaryngology’s (AAO) statement will be integral to all appeals that an otolaryngology practice would submit to third-party payers should the procedure not be paid or be underpaid.

Clinical Relevance

BDET is appropriate for adults, 18 years or older, who have experienced obstructive eustachian tube dysfunction (OETD) in one or both ears for three months or longer that “significantly affects quality of life or functional health status,” according to the statement. BDET was approved by the FDA in 2016.

BDET should not be regularly performed as part of a procedure(s) to perform balloon dilation of the sinuses if there are not very specific eustachian tube diagnostic criteria indicating the BDET procedure. Myringotomy with or without a tube placement is not a pre-requisite to performing a BDET and often the BDET can be an alternative to the myringotomy with or without the tympanostomy tube. A surgeon may want to perform a myringotomy with or without a tube placement at the time of performing a BDET, depending on the clinical indications — in particular, the presence of serous or mucoid fluid in the middle ear space.

Use BDET to Diagnose OETD

The statement stresses the importance of correctly diagnosing patients with OETD before deploying BDET. Nasal endoscopy in the office prior to considering BDET is a key tool in diagnosing OETD. The nasopharyngeal endoscopy assists the otolaryngologist in determining the treatable causes of eustachian tube dysfunction. The endoscopy also allows the otolaryngologist to assess the feasibility of the transnasal approach for deploying the BDET. The doctor can determine the size of the nasal airway and if there is a septal deviation, which may get in the way. The endoscopy of the nasopharynx also allows the doctor to examine the eustachian tube in a more detailed manner than can be performed in a manual examination. Obstruction of the eustachian tube is usually not visible within the nasopharynx because it is up to a centimeter or more inside the isthmus of the cartilaginous eustachian tube. Examination of the eustachian tube may confirm the presence of an obstruction, which is not visible on manual examination. All of this should be documented within the procedure note for the endoscopy (CPT 92511 Nasopharyngoscopy with endoscope (separate procedure)).

Comprehensive audiometry and tympanometry are critical for the diagnostic workup for OETD and should be performed prior to BDET.

The AAO statement indicates that proper patient selection will assist in successful outcomes for BDET in patients who truly have OETD.

Justify Use of an Unlisted Code

There is no CPT® code for BDET, leaving you to use the unlisted code 69799 Unlisted procedure, middle ear when performed in the outpatient setting. This is the most appropriate code available because the eustachian tube is a small passageway that connects the nasopharynx to the middle ear. The endoscope is passed down into the nasopharynx and then the balloon is deployed to dilate the eustachian tube.

When using 69799, add a comment in box 19 of the claim describing the unlisted procedure as Balloon Dilation of the Eustachian Tube and equating the unlisted code to 31296 Nasal/sinus endoscopy, surgical; with dilation of frontal sinus ostium (eg, balloon dilation). The ear procedure is similar to 31296 in complexity and risk, requiring similar skill levels for the surgeon.

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Billing the Balloon Cost

Keep in mind that when the procedure is performed in the office and the practice is supplying the balloon, the fee that is set for this procedure should be consistent with the non-facility fee for 31296 to cover the cost of the balloon. The Medicare non-geographically adjusted non-facility fee for 2019 for 31296 is $2,031.16. If the procedure is performed in the operating room, the balloon is supplied by the facility, not the surgeon. As a result, the facility fee is significantly lower because the cost of the balloon is no longer included in the fee. The Medicare non-geographically adjusted facility fee for 2019 for 31296 is $186.32. The $1,844.84 difference is the cost of the balloon to the practice when performed in the office.

If balloon dilation is performed on both eustachian tubes, 69799 would be compared to 31296-50, and the fees would be increased by 150 percent for the bilateral nature of the service. Modifiers may not be used with unlisted codes, but you can append the modifier to the reference code used to assist the payer to price the service.

Get Ready to Appeal

Many claims with unlisted codes are paid incorrectly when they are processed the first time by the third-party payer and require an appeal. The documentation must be comprehensive and include the necessary components to demonstrate medical necessity and show the risk, skills needed by the provider, and complexity of the procedure that was performed to support the fees that the practice is requesting from the third-party payer. Only excellent and complete documentation will convince the payer to assign the appropriate fee to the unlisted code.

The AAO’s 12-page Clinical Consensus Statement: Balloon Dilation of the Eustachian Tube can be found for review and download at https://journals.sagepub.com/doi/full/10.1177/0194599819848423.