Otolaryngology Coding Alert

Question: Which procedural code(s) should I use for the following operative note: Endoscopic nasopharyngeal biopsy, left of adenoidal mass, left endoscopic biopsy of left-middle meatal mass?

Indiana Subscriber

Answer: Your otolaryngologist used an endoscope to examine the nose. He then used an instrument, such as a scalpel or forceps, to biopsy two lesions or diseased mucosa. You should report 31237 (Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement [separate procedure]) for the tissue removals.

Seeing the procedure note may help with the coding. One of the biopsies occurred down in the nasopharyngeal area, not in the sinuses. You should look at 31576 (Laryngoscopy, flexible fiberoptic; with biopsy). Should the operative note demonstrate that the physician scoped down to the larynx, that it was medically necessary and the biopsy was taken from the nasopharynx, perhaps you can use 31276 (Nasal/sinus endoscopy, surgical with frontal sinus exploration, with or without removal of tissue from frontal sinus) for that mass.

Depending on the documentation, 31237 may include both biopsies as well as the diagnostic exam. If the procedure involves removing numerous lesions or taking multiple biopsies of different lesions, you could append modifier 22 (Increased procedural services) to 31237. The modifier would indicate the otolaryngologist’s increased work. In this case, you would need to submit a paper claim and appeal for higher reimbursement.

Note: The Correct Coding Initiative (CCI) bundles 31276 and 31231. Payers following CCI will only reimburse 31276 should you report them both without a modifier and supporting documentation.