Otolaryngology Coding Alert

Question: Our surgeon performed an endoscopic middle meatus anstrostomy. I’m leaning toward code 31256 but am not sure if it’s correct. The physician also performed a right sided endoscopic nasal/sinus polypectomy during the same session, so I’m not sure if that changes the coding. What’s your recommendation? 

Oklahoma Subscriber

Answer:  You are correct in considering 31256 (Nasal/sinus endoscopy, surgical, with maxillary antrostomy) for the main procedure. The endoscopic polypectomy is represented by 31237 (Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement [separate procedure]).

You don’t specify whether the physician completed 31256 on the right or left side. If the procedure was done on the left, you can bill 31256 for the left along with 31237-59 (Distinct procedural service) for the right side. If both procedures were performed on the right side, however, only 31256 can be billed. If the 31256 was performed bilaterally, only 31256-50 (Bilateral procedure) can be billed.

Correct Coding Initiative (CCI) edits bundle 31237 into 31256, so you would normally report only 31256 for the encounter. CCI does allow you to append a modifier (such as 59, Distinct procedural service) to 31237 in some circumstances and report both procedures. Speak with your physician and verify that the documentation supports reporting both services before submitting both codes.