Peruse This Primer for Nasal Polyp Removal Coding Precision
And mind these modifiers to avoid denials. Nasal polyps are benign mucosal growths that can obstruct airflow through the nasal passages and sinuses, leading to congestion, infection, and impaired breathing. When conservative therapies such as corticosteroid sprays or nasal irrigation are ineffective, surgical removal becomes necessary. For medical coders and compliance professionals, understanding how to report nasal polyp procedures accurately is essential for proper adherence to current CPT® and payer-specific guidelines, ensuring reimbursement and reducing denials. Understand the Procedure Surgical removal of nasal polyps can be performed through either a non-endoscopic (open) approach or an endoscopic technique. The non-endoscopic method relies on direct visualization, typically using nasal specula and forceps, and is often performed in an office or outpatient setting for simple cases. The endoscopic approach, by contrast, uses a rigid or flexible fiberoptic endoscope, providing illumination and magnification to allow for precise removal of polyps and other diseased tissue from the nasal cavity or sinuses. Endoscopic surgery has largely replaced traditional methods due to its improved visualization, ability to address deeper pathology, and lower recurrence rates. However, each approach is assigned a distinct CPT® code, and coders must carefully select the one that aligns with the surgeon’s documentation. Make Note of These Nasal Polyp Excision Codes The CPT® code set provides specific options depending on the surgical approach and extent of the excision. For non-endoscopic removal, 30110 (Excision, nasal polyp(s), simple) describes a simple excision of nasal polyps, while 30115 (… extensive) represents a more extensive procedure. These codes are typically used when the physician removes polyps from the nasal cavity without the aid of an endoscope. If both sides of the nasal cavity are treated during the same session, you should report the procedure with modifier 50 (Bilateral procedure). Alternatively, you may use modifiers RT (Right side) or LT (Left side) for unilateral procedures. For endoscopic removal, the correct code is 31237 (Nasal/sinus endoscopy, surgical; with biopsy, polypectomy, or debridement (separate procedure)). This code applies when the surgeon uses an endoscope to remove polyps, perform a biopsy, or conduct a therapeutic debridement to clear diseased or obstructive tissue. Take Guidance from CPT® Assistant A frequently misunderstood point is whether a physician may report 31237 more than once when both a biopsy and a debridement are performed on the same side. According to CPT® Assistant Volume 31, Issue 11 (November 2021), this is not permitted. The biopsy is considered inherent to the polypectomy or debridement when performed on the same side and during the same encounter. Therefore, only 1 unit of 31237 should be reported per laterality, regardless of whether a biopsy, debridement, or both are completed. This rule aligns with broader CPT® coding principles: when tissue sampling occurs as part of a more extensive removal, it is not separately billable. The coder must review the operative note to determine if the biopsy represents a distinct, medically necessary service performed in a different anatomic location. If not, it should be bundled into the primary procedure. Know When to Report 31237 You should use 31237 when the surgeon performs an endoscopic procedure that includes visualization and removal of tissue, whether as a biopsy, polypectomy, or debridement. The code is also appropriate when the procedure is performed independently rather than as part of a larger functional endoscopic sinus surgery (FESS). When a polypectomy is performed within the same sinus, it is considered part of the primary sinus procedure and not separately reportable. However, if the surgeon removes polyps from a different sinus or nasal cavity not included in the FESS, you may report 31237 with modifier 59 (Distinct procedural service). Proper documentation must support that the surgeon performed the endoscopy on a separate anatomic region and was medically necessary. Consider These Postoperative Debridement Coding Situations Many patients undergoing sinus surgery require postoperative debridement to promote healing and maintain sinus patency. This may involve removing crusts, necrotic tissue, or mucus that obstructs drainage. Such procedures can also be reported using 31237 provided the work involves significant tissue removal and is not limited to routine suctioning or cleaning. Documentation should clearly demonstrate the medical necessity for debridement such as infection risk, obstruction, or delayed healing and describe the extent of tissue removal. Some payers consider postoperative debridement part of the global surgical package, while others allow separate reimbursement when justified. In those cases, you should append modifier 52 (Reduced services) if the debridement is less extensive than a full polypectomy. Select the Correct ICD-10-CM Code Diagnosis coding must accurately reflect the site and nature of the polyp. Common ICD-10-CM codes include: When the location is not documented, you may us J33.9 (Unspecified nasal polyp), although payers generally prefer site-specific coding. Coders should verify whether the documentation indicates an inflammatory polyp or a neoplastic lesion. Neoplastic lesions, whether benign or malignant, require different CPT® codes, such as 30117 (Excision or destruction (eg, laser), intranasal lesion; internal approach) or 30118 (… external approach (lateral rhinotomy)) for excision of intranasal lesions. Accurate coding depends on both operative and pathology reports. Know These Documentation Essentials Accurate procedural reporting depends heavily on the completeness of the operative note. Documentation should specify the surgical approach (endoscopic or non-endoscopic), the extent of removal, the anatomic location, and whether the procedure was unilateral or bilateral. It should also describe whether any biopsy, debridement, or concurrent FESS procedure was performed, and if the work was distinct from another service. The note must include a clear statement of medical necessity explaining why the procedure was performed —such as obstruction, infection, or failed medical management — and identify the tools or endoscopes used. These details not only support accurate code selection but also defend the claim in the event of an audit or payer review. Amanda Brewer, RHIT, CCS, CRC, CPMA, Senior Auditor Educator Risk Adjustment Coding,
Audit and Education, Pinnacle Enterprise Risk Consulting Services, LLC
