Wiki 31259---YES OR NO?

[bag4498]

In desperate need of help with this one, would love some insight.

Conflicting information I guess is what led me to thinking 31259. According to the snippit below, he did a ethmoidectomy with sphenoidotomy. So the question is, does his note satisfy the remaining portion of the code description, which is
“With removal of sphenoid sinus tissue”? Reading his OP note below he took a specimen from the mucosa within the sphenoid sinus proper. According to the google search of “what is mucosa”- Mucosa it is a moist tissue that lines certain parts of the inside of your body. This came from medlineplus.gov. But reading further into the Op note he states “no biopsy was taken of the left sphenoid sinus, no specimen was taken of the right sphenoid sinus”…..but yet if I go to pathology (which I included below) it states “Labeled as "left sphenoid sinus" and consists of one piece of
pink-purple soft tissue”. Very interesting indeed.





FROM PATHOLOGY:
Labeled as "left sphenoid sinus" and consists of one piece of
pink-purple soft tissue measuring 1.0 x 0.8 x 0.3 cm. The specimen is
entirely submitted in a single cassette.

 

[freespririt0806]

i believe at the end of the op note where he states no biopsy taken from the LT sphenoid should be corrected as earlier he states he did biopsy the degenerated mucosa of the LT sphenoid and you have a path to correlate it . I am not a fan of the " same procedure performed on the other/contralateral side". That being said

 

[freespririt0806]

sorry click post instead of preview
I would have coded that
31296 lt
31257 lt due to tissue removal of the sphenoid 1 side
31255 59 rt
31287 59 rt
is there any documentation of Medtronic?

 

[b.cobuzzi]

I see documentation of image guidance, so I would add 61782

Since the left included tissue removal, the combination code 31259 should be used, not 31257 for that side.
And why are the total ethmoid and sphenoid on the right unbundled. They should be coded using the combination code 31257

Also, if this is Medicare Part B or a payer like United Healthcare that recognizes the X[ESPU] modifiers for separate procedures, I would use XS instead of the 59 modifier. Payers are monitoring usage of the 59 modifier and red flagging usage, looking for inappropriate unbundling. Usage of the X[ESPU] modifiers tells the payers that you not only know why you are unbundling the codes, but you have documentation to support this reason.

I would code this as it is:
31296 LT
31259 LT due to tissue removal of the sphenoid 1 side (total ethmoid and sphenoid with tissue removal)
31257 XS RT (total ethmoid and sphenoid without tissue removal)
61782

The doctor did a horrible job of dictation. He or she repeated the work in the left sphenoid and frontal twice in the op note and could not be bothered to put the details of what he or she did on the right sphenoid. I have no idea if he did anything in the right frontal sinus and I assume you just did not include what is said about the right inferior turbinate. The last line, "Attention was then turned to the right inferior turbinate" is a repeat of what was said in the middle of the note, just before the right ethmoidectomy was performed. This op note is a jumble and should be re-dictated, in my opinion. The details of what was performed on both sides should be included. The right sphenoid did not look or perform like the left sphenoid but he has a statement that the "same procedure was performed except" That is horrible documentation.