Wiki CPT for turbinate submucous resection

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Blackhorse

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POSTOPERATIVE DIAGNOSES:​

1) Inferior turbinate hypertrophy.
2) Adenoid hypertrophy.
3) Nasopharyngeal obstruction due to soft tissue, possible adenoiditis.

PROCEDURES PERFORMED:
1) Bilateral nasal endoscopy with nasopharyngeal biopsy.
2) Adenoidectomy.
3) Bilateral inferior turbinate submucous resection using submucosal radiofrequency current


I code 31237-RT, 31237-LT, 42831, 30140-RT, 30140-LT for all the procedures. Our coder codes all CPT same as mine except for submucous resection, she uses 30802 which I don't think is correct.
 
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: Minimal.
COMPLICATIONS: None.
SPECIMENS: Biopsy of nasopharyngeal soft tissue.

OPRATIVE FINDINGS: Inferior turbinates were reduced and examination of nasal cavity revealed no polyps. Granular appearing lymphoid tissue filled the nasopharynx superiorly obstructing at the level of the choana, which clinically was consistent with adenoid tissue, which was biopsied prior to ablation for adenoidectomy.

DESCRIPTION OF PROCEDURE: The patient was explained the risks and the consent signed. She was taken to the operating room and general anesthesia was induced. Nose and face were sterilely prepped and draped. Nose was decongested with Afrin-soaked cottonoids and examined with a O degree nasal telescope. Both sides showed turbinate hypertrophy with no polyps. Nasopharynx was examined nasally as well. There was lymphoid tissue bilaterally obstrncting at the level of the choana, more pronounced on the left than right.

I used straight cutting sinus forceps to obtain ample specimen from the left choana and this was sent for permanent review and the cottonoid placed for hemostasis as the inferior turbinates were treated with the ArthroCare turbinate wand, which was used to pierce the tip of the left inferior turbinate and passed to the posterior third of the structure and activated submucosally at a setting of 4 for 10 seconds.

Additional lesions were made in the middle and anterior third of the structure resulting in its volumetric reduction and the mucosa was preserved as the body was outfrachired with a Freer. This was repeated bilaterally. The cottonoid was removed and the nose hemostatic. The mouth gag retractor was introduced to expose the oropharynx. A red rubber catheter was passed through the nose and grasped from the mouth to retract the palate. A mirror confirmed what appeared to be adenoid tissue at the level of the choana bilaterally, which was ablated using the ArthroCarc wand i11 the setting of 9 down to the posterior pharyngeal wall, which was cauterized for hemostasis. The throat was reinspected and clear and the procedure terminated.
 
The documentation here makes the coding challenging. I see why your colleague chose 30802 instead of 30140 - although the header describes the procedure as "inferior turbinate submucous resection", the dictation does not clearly describe actual resection of any tissue. The same thing applies with the adenoidectomy, only ablation is described, not resection. It might be appropriate to query the provider for clarification of both of these. I would not code 31237-RT because I only see one biopsy documented, which is on the left. Unfortunately, you then cannot code the diagnostic endoscopy on the right side as it can't be unbundled from the biopsy on the left. Hope this maybe helps some.
 
Blackhorse said:
30802 is for ablation of submucosal, is adenoid tissue submucosal?
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No, 30802 is just for the ablations of the inferior turbinates. But I think the use of the adenoidectomy code 42831 could be questionable if the provider is only documenting an ablation of some of the tissue and not a removal. It's also not clear if this is a primary or secondary adenoidectomy. Sorry for the confusion.
 
Blackhorse said:
Does ArthroCare turbinate wand normally used for fast submucosal resection?
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I believe it can be, but I would confirm with the physician if they are using it for that purpose and if so, recommend that it be documented in the body of the operative note so that it would be clear to an auditor if ever necessary.
 
Documentation does not support removal of adenoids, if he did it have him addend his note
30802 is appropriate and he did use the wand in a submucosal manner
 
Blackhorse, Thomas and tiaralady, there is documentation of destruction of the adenoids. From the note:

The mouth gag retractor was introduced to expose the oropharynx. A red rubber catheter was passed through the nose and grasped from the mouth to retract the palate. A mirror confirmed what appeared to be adenoid tissue at the level of the choana bilaterally, which was ablated using the ArthroCarc wand i11 the setting of 9 down to the posterior pharyngeal wall, which was cauterized for hemostasis. The throat was reinspected and clear and the procedure terminated.

When coding tonsil and adenoids, the method of removal is agnostic to the actual removal/destruction. Tonsils and adenoids can be removed with cautery, cautery, scalpel, radiofrequency, etc. Arthrocare is radiofrequency technology. Doctor destroyed the adenoid tissue using radiofrequency, and so he did the adnoidectomy.

The documentation for the biopsy of the nasophyaryngeal tissue is very weak. And I hate when surgeons say they did the same on the other side. Are we to assume that the inferior turbinates were reduced with radiofrequency AND a biopsy was taken from the other side or was only one of the two procedures performed. The lack of detail and accuracy in the operative note leaves this all open and unable to support. I would request the surgeon to amend the operative note with the details as to what he did on the second side. And if the biopsy was taken bilaterally, you would not code it 31237-RT, 31237-LT. You would code it as a bilateral procedure, 31237-50.

One of the things that makes this surgeon difficult to code is his very compact dictation. He is too compact, leaving the detail up for interpretation and that could leaving him in a difficult situation when and if the surgeon is audited.
 
b.cobuzzi said:
Blackhorse, Thomas and tiaralady, there is documentation of destruction of the adenoids. From the note:

The mouth gag retractor was introduced to expose the oropharynx. A red rubber catheter was passed through the nose and grasped from the mouth to retract the palate. A mirror confirmed what appeared to be adenoid tissue at the level of the choana bilaterally, which was ablated using the ArthroCarc wand i11 the setting of 9 down to the posterior pharyngeal wall, which was cauterized for hemostasis. The throat was reinspected and clear and the procedure terminated.

When coding tonsil and adenoids, the method of removal is agnostic to the actual removal/destruction. Tonsils and adenoids can be removed with cautery, cautery, scalpel, radiofrequency, etc. Arthrocare is radiofrequency technology. Doctor destroyed the adenoid tissue using radiofrequency, and so he did the adnoidectomy.

The documentation for the biopsy of the nasophyaryngeal tissue is very weak. And I hate when surgeons say they did the same on the other side. Are we to assume that the inferior turbinates were reduced with radiofrequency AND a biopsy was taken from the other side or was only one of the two procedures performed. The lack of detail and accuracy in the operative note leaves this all open and unable to support. I would request the surgeon to amend the operative note with the details as to what he did on the second side. And if the biopsy was taken bilaterally, you would not code it 31237-RT, 31237-LT. You would code it as a bilateral procedure, 31237-50.

One of the things that makes this surgeon difficult to code is his very compact dictation. He is too compact, leaving the detail up for interpretation and that could leaving him in a difficult situation when and if the surgeon is audited.
Click to expand...
Thank you very much(y)
 
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