Wiki CPT 31231 and what is required to be documented to meet code?

[codingrules]

Hi,
I am inquiring what needs to be documented in the procedure note to meet CPT 31231 (nasal endoscopy)?

The CPT code 31231 Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure) explains that "Diagnostic evaluation refers to employing a nasal/sinus endoscope to inspect the interior of the nasal cavity and the middle and superior meatus, the turbinates, and the sphenoethmoid recess. Any time a diagnostic evaluation is performed, all of these areas are inspected and a separate code is not reported for each area. If all of these areas are not fully inspected because it is deemed clinically unnecessary or due to an altered clinical presentation, it may be appropriate to append modifier 52 if no repeat examination is planned. If a repeat examination is planned, modifier 53 may be appropriate. Surgical sinus endoscopy always includes a sinusotomy, when appropriate, and diagnostic endoscopy; however, diagnostic endoscopy can be identified separately when performed at the same surgical session as an open procedure. "

My question is, if the provider documents inspecting the interior nasal cavity, middle meatus, the turbinates and the sphenoethmoid recess but does not document any about the superior meatus-- would coding 31231 with modifier 52 be appropriate? Since the sphenoethmoid recess and superior meatus are in the same area, I am not clear if the modifier 52 is appropriate.

Thank you,
Julie

 

[unicorn80]

I believe you would be correct to append modifier 52-reduced services because the doctor is not discontinuing the procedure entirely he just did not feel inspecting the superior meatus was necessary for the purpose of the procedure. The CPT book also says under the endoscopy section that if all elements of are not fully examined to append modifier 52.