Otolaryngology Coding Alert

Question: A surgeon plans a concha bullosa resection. The patient's nasal passage is so blocked with sinus mucosa and polyps that the otolaryngologist has to remove the endoscope and excise numerous polyps bilaterally. He then reinserts the endoscope and performs further polypectomy on the left side before getting to the patient's sinus where he removes the middle turbinate to open a concha bullosa. Can I separately bill the polypectomy with 30115?

Wisconsin Subscriber

Answer: Code 31240 (Nasal/sinus endoscopy, surgical; with concha bullosa resection) includes endoscopic polypectomy (31237, ... with biopsy, polypectomy or debridement [separate procedure]), as well as direct (30115, Excision, nasal polyp[s], extensive; or 30117, Excision or destruction [e.g., laser], intranasal lesion; internal approach). The polyps- location in the nasal cavity or sinus cavity does not affect whether the polypectomy is included. CPT considers polypectomy inclusive as a means of gaining access to the sinus -- without removing the polyps, the surgeon couldn't perform the concha bullosa resection.

But the inclusion applies only to the same-side polypectomy and sinusoscopy. Your case indicates bilateral nasal polyp removal and unilateral concha bullosa resection. The left-side polypectomy occurs on a separate site from the right-side sinusoscopy, so you may report the polypectomy on the left side.

You may appropriately unbundle the code pair by appending modifier 59 (Distinct procedural service) to the polypectomy code. Assign 30115 or 30117, depending on the destruction method and approach.

Don't overlook: When polyp removal requires substantially greater work than the entrance work associated with a typical 31240 and documentation supports this claim, consider adding modifier 22 (Increased procedural services) to the FESS code.

File the claim electronically. Then, submit a cover letter indicating the factors, such as anatomic anomaly or previous sinus surgery associated with the quantifiable increased work, for instance extra time removing polyps. Be sure to indicate that you are submitting documentation for a previously electronically submitted claim and ask for more money for the procedure's increased work.