bvansickle
New
Provider op note: The middle turbinate was medialized. The uncinate process was removed with side-biting forceps. The maxillary sinus ostium was located, culture was taken and the maxillary sinus ostium was widened using side biting forceps and straight-biting Tru Cut forceps removing polypoid material from the ostium. The maxillary sinus mucosa appeared hypertrophied but was left intact.
Provider reports 31267 performed.
Per coder: Per CPT, one cannot report 31267 if he/she exclusively removes tissue from the ostium and not the maxillary sinus itself. Based on the CPT code description (Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with remove of tissue from maxillary sinus); if tissue removal from the ostium occurs during the maxillary antrostomy, but it does not extend into the maxillary sinus, CPT code 31267 is not substantiated; op note states the sinus muso was left intact.
Coder: Provider should report 31256 not 31267.
If tissue is removed but the sinus mucosa is left ‘intact’ which CPT, 31267 or 31256 to be reported?
Provider reports 31267 performed.
Per coder: Per CPT, one cannot report 31267 if he/she exclusively removes tissue from the ostium and not the maxillary sinus itself. Based on the CPT code description (Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with remove of tissue from maxillary sinus); if tissue removal from the ostium occurs during the maxillary antrostomy, but it does not extend into the maxillary sinus, CPT code 31267 is not substantiated; op note states the sinus muso was left intact.
Coder: Provider should report 31256 not 31267.
If tissue is removed but the sinus mucosa is left ‘intact’ which CPT, 31267 or 31256 to be reported?