Otolaryngology Coding Alert

Question: The otolaryngologist applied topical anesthesia before placing three pledgets in each of the patient’s nasal cavities. He did the procedure because of a possible CSF leak. The doctor would like to bill 78630, but I don’t think this is right. What do you suggest?

South Dakota Subscriber

Answer: Code 78630 (Cerebrospinal fluid flow, imaging [not including introduction of material]); cisternography) is not your best option because your physician is not performing any imaging. 

If your physician did more than just place the pledgets and did a sinus endoscopy with repair of the CSF leak, you can consider either 31290 (Nasal/sinus endoscopy, surgical, with repair of cerebrospinal fluid leak; ethmoid region) or 31291 (Nasal/sinus endoscopy, surgical, with repair of cerebrospinal fluid leak; sphenoid region) depending on the area of the CSF leak. However, both of these codes represent quite a bit more than anesthetizing the nose and introducing the pledgets. The clinical responsibilities involved for these two codes include the following:

After administration of anesthesia, a rigid or flexible endoscope is performed with repair of a cerebrospinal fluid (CSF) leak in the ethmoid region. A topical nasal decongestant and local anesthesia are applied as needed to the nasal mucosa. The endoscope is introduced to the nose. When the nasal cavity and paranasal sinuses are inspected for disease or abnormalities, the site of the CSF leak is identified. The CSF leak is then repaired using muscle tissue to plug the defect.  The muscle plug is then covered with fascia.

If your operative note does not reflect the above procedure, your best code choice is 30999 (Unlisted procedure, nose). Include documentation of exactly what the surgeon did and why the procedure was medically necessary.