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.

Code 31237 includes 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 (Unusual 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.