Elaine Posted Thu 26th of April, 2012 21:38:49 PM
How would you code the following:
Starting on the patient's right-hand side some gross nasal polyps were removed with the microdebrider. The fontal sinus balloon introducer was placed, a Luma wire was placed into the frontal sinus and this was dilated with a 6 x 16 balloon. After the dilatation a curved microdebrider was placed into the frontal sinus and a very wide frontal sinusotomy was performed. The uncinate process was divided with a backbiting forceps and removed superiorly and inferiorly. The natural ostium of the maxillary sinus was located and this was opened posteriorly and inferiorly. An enormous amount of inspissated thick mucus and debris was removed from the sinus. A fairly complete anterior and posterior ethmoidectomy was then performed using the image guided system. The most posterior ethmoid air cell was identified with the image guided probe...
SuperCoder Answered Thu 26th of April, 2012 21:55:31 PM
If the procedure is endoscopic report 31295 for frontal sinusotomies
31267 for maxillary
31255 for ethmoids
The report is incomplete , i could see the documentation of right side only, however if performed on left side report it with 50 modifier.