Otolaryngology Coding Alert

Question: A primary care physician (PCP) referred a patient to our otolaryngologist for recurrent ear, nose, and throat issues. She has a history of recurrent sinusitis; about four times a year for the past three years. These episodes did not resolve even after the PCP used nasal steroids, lavage, and antibiotics. The patient’s associated symptoms include itchy nose, postnasal drip, sneezing, itchy eyes, bilateral facial pain, and dull bilateral periorbital pressure.

Workup included a nasal endoscopy, allergy testing, nasal sprays, antibiotics, and computed tomography (CT) of the sinuses. Allergy testing showed no significant sensitivity to allergens. CT of the sinuses showed mucosal thickening with complete opacification of the right maxillary sinus along with inflammatory changes in the anterior ethmoid air cells bilaterally. All other sinus cavities were clear.

After conservative medical management failed, the otolaryngologist performed a bilateral endoscopic anterior ethmoidectomy and right sided maxillary balloon sinuplasty. Final diagnoses were chronic maxillary sinusitis and chronic ethmoidal sinusitis. How should we code this encounter?

Utah Subscriber

Answer: On the claim, you’ll need to be sure to pair the proper CPT^® and ICD-10 codes in order to submit the clearest, most correct claim.

First, report 31295 (Nasal/sinus endoscopy, surgical; with dilation of maxillary sinus ostium [e.g., balloon dilation], transnasal or via canine fossa) with modifier RT (Right side) for the sinuplasty with J32.0 (Chronic maxillary sinusitis) appended to represent the patient’s condition.

Then, report 31254 (Nasal/sinus endoscopy, surgical; with ethmoidectomy, partial [anterior]) with modifier 50 (Bilateral procedure) appended to show that your otolaryngologist performed the sinuplasty bilaterally. Also, append J32.2 (Chronic ethmoidal sinusitis) to 31254 to represent the patient’s condition.