My provider and I don't see eye to eye on the coding of the following procedure note. I would like to ask my fellow AAPC members if the following note should be coded as CPT 31276 or 31296?
After this had been done, a 0-degree scope was used during the entire procedure for evaluation and opening of the sinuses on both sides. The procedure was begun in the right nasal cavity.** A balloon apparatus was used in order to dilate the right nasofrontal duct. A 6 x 16 mm balloon was then placed up into the right* frontal sinus after it had been entered and this was confirmed with the Luma light source. The balloon was brought up to 12 atmospheres and the nasofrontal duct was dilated.* The right frontal sinus was then irrigated with saline.* A small amount of material came readily from the frontal sinus .* After a couple of more irrigations of saline on material that came out was clear.* Attention was turned toward the left side.* A balloon apparatus was used in order to dilate the left nasofrontal duct. A 6 x 16 mm balloon was then placed up into the left frontal sinus after it had been entered and this was confirmed with the Luma light source. The balloon was brought up to 12 atmospheres and the nasofrontal duct was dilated. An irrigator was then placed deeply into the left frontal sinus and the sinus was irrigated.* No material came from the left frontal sinus. The sinus was irrigated with saline.
Any advice would be greatly appreciated.
Thank you in advance,
Marisa
After this had been done, a 0-degree scope was used during the entire procedure for evaluation and opening of the sinuses on both sides. The procedure was begun in the right nasal cavity.** A balloon apparatus was used in order to dilate the right nasofrontal duct. A 6 x 16 mm balloon was then placed up into the right* frontal sinus after it had been entered and this was confirmed with the Luma light source. The balloon was brought up to 12 atmospheres and the nasofrontal duct was dilated.* The right frontal sinus was then irrigated with saline.* A small amount of material came readily from the frontal sinus .* After a couple of more irrigations of saline on material that came out was clear.* Attention was turned toward the left side.* A balloon apparatus was used in order to dilate the left nasofrontal duct. A 6 x 16 mm balloon was then placed up into the left frontal sinus after it had been entered and this was confirmed with the Luma light source. The balloon was brought up to 12 atmospheres and the nasofrontal duct was dilated. An irrigator was then placed deeply into the left frontal sinus and the sinus was irrigated.* No material came from the left frontal sinus. The sinus was irrigated with saline.
Any advice would be greatly appreciated.
Thank you in advance,
Marisa