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POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

End User License Agreement

These materials contain Current Dental Terminology, Fourth Edition (CDT), copyright © 2002, 2004 American Dental Association (ADA). All rights reserved. CDT is a trademark of the ADA.

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  1. Subject to the terms and conditions contained in this Agreement, you, your employees, and agents are authorized to use CDT-4 only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT-4 is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT-4. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.
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January 21, 2022

Sinus Implant Billing and Coding Instructions

Steroid eluting Sinus implants:

  • SINUVA® 1,350mcg
  • PROPEL® 370 µg
  • PROPEL® Mini 370 µg
  • PROPEL® Contour 370 µg
  • PROPEL® Mini SDS 370 µg

Coverage is based on the Food & Drug Administration (FDA) indications:

SINUVA is FDA approved for placement in the ethmoid sinus, for the treatment of nasal polyps in patients ≥ 18 years of age who have had ethmoid sinus surgery (ESS). SINUVA may also be placed in the office in patients with previous ESS as alternative to repeat sinus surgery.

The PROPEL sinus implants are placed at the time of surgery and are intended to maintain patency and locally deliver steroid to the sinus mucosa in patients ≥18 years of age following sinus surgery:

  • PROPEL and PROPEL Mini SDS for the ethmoid sinus;
  • PROPEL Mini for the ethmoid sinus/frontal sinus opening; and
  • PROPEL Contour for the frontal/maxillary sinus ostia.

The FDA label indicated these devices should be inserted by physicians trained in otolaryngology.

The devices are to be placed under direct endoscopic visualization.

For SINUVA sinus implants:

SINUVA - use HCPCS J7402 (effective 4/1/21)

PLUS

CPT code endoscopic sinus procedure code (31231-31298).
If solely for endoscopic implantation of J7402, use code 31299 (Unlisted procedure, accessory sinuses). Enter “SINUVA” in the narrative for code 31299:

  • Electronic claims - Loop 2300, NTE Segment (header level) or Loop/Element 2400 SV101-7, NTE Segment (line level)
  • Paper Claims - Item 19 of CMS-1500 form or Form Locator 80 on the UB-04 Form.

SINUVA is approved for ethmoid sinus placement only. ICD-10 codes:

  • J33.0 - Polyp of nasal cavity
  • J33.1 - Polypoid sinus degeneration
  • J33.2 - Chronic ethmoid sinusitis

For PROPEL sinus implants:

PROPEL (ethmoid sinus)
PROPEL Mini (ethmoid or frontal sinus)
PROPEL Mini with Straight Delivery System (SDS) (ethmoid sinus)
PROPEL Contour (frontal or maxillary sinus)

Use J3490 (Part B) or C9399 (Part A)

PLUS

Surgical code: Providers should always report the CPT code(s) which most accurately describe the services performed in association with placement of a drug-eluting sinus implant.

If the procedure is performed bilaterally, the CPT codes may be appended with modifier -50, except for code 31231 (which is already valued for bilateral).

PROPEL Claim Submission: Part B

  • Submit unlisted HCPCS code J3490
    • Include the name of the drug, national drug code (NDC) number, and the exact dosage administered
      • Electronic Media Claims (EMC) -  report this information in Loop 2300, NTE Segment (header level) or Loop/Element 2400 SV101-7, NTE Segment (line level). If additional space is needed, Loop 2400 NTE 02 may be utilized in addition to SV101-7.
      • Paper claims (if you are approved to submit paper claims) - report this information in item 19 on the CMS-1500 claim form.

PROPEL Claim Submission: Part A

  • Submit unlisted HCPCS code C9399
    • Include the name of the drug, the national drug code (NDC) number, and the exact dosage administered
      • Electronic Media Claims (EMC): report this information in Loop 2300, NTE Segment (header level) or Loop/Element 2400 SV101-7, NTE Segment (line level). If additional space is needed, Loop 2400 NTE 02 may be utilized in addition to SV101-7. (Note: See additional information under Claim Submission: Part B)
      • Paper claims (if approved to submit paper claims): report this information in Form Locator 80 on the UB-04 Form.

The ICD-10 code used should reflect the cavity inserted (maxillary, frontal or ethmoid sinus)

  • J32.0 - Chronic maxillary sinusitis
  • J32.1 - Chronic frontal sinusitis
  • J32.2 - Chronic ethmoidal sinusitis.

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