Outpatient Facility Coding Alert

Question: The surgeon did a right middle meatus antrostomy and resection of concha bullosa. He documented the procedure as “Polypoid tissue was removed from the middle meatus area on the right side. An uncinectomy was performed in the usual fashion. Inflammatory tissue was removed from within and around the sinus cavity opening. A sickle knife was used to bivalve the middle turbinate. The medial portion was removed with the concha bullosa.” Could you please advise what code we should use for the antrostomy?

Chicago Subscriber

Answer: The code 31240 (Nasal/sinus endoscopy, surgical; with concha bullosa resection) is used for nasal/sinus endoscopy with concha bullosa resection. Hence, this code would take care of resection of concha bullosa along with meatus antrostomy.

A word of caution: The otolaryngologist should document the endoscopic excision of the concha bullosa very well along with antrostomy. A well documented operative note shows the work involved in the added procedure of resection of concha bullosa. This will make a difference if the payer denies the claim and you file an appeal so the ENT is not denied payment on the extra work he performs for endoscopic resections.