Marie Posted Mon 29th of January, 2018 11:18:46 AM
Would it be correct to use 31292 for the mucocele decompression and 31295 for the balloon that was used? A 0° endoscope was introduced through the mouth. The image guidance system was used to explore the anatomy. The anatomy is quite distorted from the trauma and prior reconstruction. Using 1% Xylocaine with 1-100,000 epinephrine, the lateral nasal wall was infiltrated. Next a 45° Thru cut forceps was used to make an incision. The mucosa is scarred and quite difficult to cut. Next using various instruments, the mucosa was denuded. Decompression was not possible. Therefore, an 18-gauge needle was introduced on a control syringe and thick drainage was found. The area was widened and the mucocele was partially decompressed. Using curved suction, the mucocele was further decompressed. There appears to be a large cavity present. A Luma guidewire was introduced and a 6 mm x 16 mm balloon was deployed to 12 atmospheres of pressure. This was done twice to ensure the entire tract was patent. This cavity was completely suctioned out and decompressed.
SuperCoder Answered Tue 30th of January, 2018 08:32:29 AM
As per the above documentation as decompression was partially performed but the anatomical site is not mentioned hence CPT code 31292 (medial or inferior wall) will not to be appropriate. If Documentation states medial or inferior then only cpt code 31292 is appropriate to bill. CPT code 31295 would be appropriate for the ballon dilation scenario.
Hope this helps!
Marie Posted Tue 30th of January, 2018 09:12:41 AM
The anatomical site (medial or inferior) is not mentioned in the report, so, should I query the physician or would I have to use an unlisted code to cover for this? Thanks.
SuperCoder Answered Wed 31st of January, 2018 06:43:34 AM
Please check the anatomical site with the documentation received or confirm the anatomical site from your provider to bill correct cpt.
Hope this helps!