Otolaryngology Coding Alert
Make Certain MD Gets Credit for 31267
Question: My physician performed:
left endoscopic maxillary antrostomy with biopsy, sinus tissue contents.
left maxillary sinusoscopy.
On the superbill, the surgeon coded 31256 and wrote as an extra procedure “maxillary sinoscopy.” I think the otolaryngologist is correct not to bill 31267, because he did not remove tissue. But how should I code the sinusoscopy?
Answer: The otolaryngologist actually does deserve credit for 31267 (Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus). Because the surgeon takes a biopsy of the maxillary sinus and a biopsy involves taking tissue, the procedure qualifies as 31267. Code 31267 does not require complete tissue removal, just tissue removal.
When the otolaryngologist performs a maxillary antrostomy and doesn’t remove any tissue, such as a biopsy or polyp, you should instead assign 31256 (Nasal/sinus endoscopy, surgical, with maxillary antrostomy).
On the other hand, you should not code the sinuscopy. Surgical endoscopy (such as 31256-31267) includes diagnostic endoscopy (for instance 31233, Nasal/sinus endoscopy, diagnostic with maxillary sinusoscopy [via inferior meatus or canine fossa puncture]).
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