Otolaryngology Coding Alert

Question: Our physician completed an endoscopic middle meatus anstrostomy and right side endoscopic nasal/sinus polypectomy. My co-worker recommended 31256, but I’m not sure this is correct. How do we code for both procedures?

Nebraska Subscriber

Answer: It is not clear which side the endoscopic middle meatus antrostomy was performed on. If it was performed on the left side (separate location), you would submit 31256-LT (Nasal/sinus endoscopy, surgical, with maxillary antrostomy) for the endoscopy and 31237-59-RT (Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement [separate procedure]) for the endoscopic polypectomy on the right side.

Coding edits from the Correct Coding Initiative (CCI), however, bundle 31237 into 31256. If you have clear documentation differentiating between the services, you can possibly report both codes and append the 59 modifier to 31237 to indicate that this procedure was performed on a different site in order to break the bundling edit. If the documentation doesn’t support two different sides, only submit 31256.