Wiki Incisional biopsy of left maxillary mass

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nan.coder

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Good afternoon all, Please assist with CPT code for an incisional biopsy of a left maxillary mass.

OP note states - "15 blade was used to incise through gingival buccal sulcus. Dissection underneath mucosa was done superiorly. Copious straw-colored fluid was expressed through maxillary sinus. An incisional biopsy was then taken using scissors through the cyst wall as it appeared to be eroding through anterior face of maxillary sinus. Incision was closed."

Pathology report states specimen consistent with diagnosis of central giant cell granuloma.

Please steer me in the right direction for CPT code.

Thank you all.

Nancy Boyle, CPC, CRC
nboyle@soundhealthservices.com
 
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31299 - Unlisted procedure, accessory sinuses and use 31030 as a comparative for reimbursement as it is the closest code to describe the approach and part of the procedure.
 
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Nan.coder, are you sure that only a mass was excised? Nothing else was performed on the maxillary sinuses?

I am wondering if you could code 31032-52 - Sinusotomy, maxillary (antrotomy); radical (Caldwell-Luc) with removal of antrochoanal polyps

From Supercoder/AAPC Coder
In this procedure, the provider makes an incision in the gums. The provider then uses an instrument to remove the entire mucus membrane of the antrum creating better drainage to the nose from the maxillary sinus. She then dissects the anterior wall to remove the polyp and other diseased material.
 
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Barb Cobuzzi, thank you for your response. The surgeon's note and recall were inconsistent. He actually went with the 31032-52. Thank you for your assistance.

Nancy Boyle, CPC, CRC
 
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