Understand Removal or Reduction in This Turbinate Reduction Op Note
Question: Our surgeon documented the following for an in-office turbinate reduction: Starting at the head of the inferior turbinate, tissue was removed and reduced in an anterior to posterior direction by a submucosal approach using the REFLEX ULTRA turbinate wand, along the entire length of the turbinate, resulting in submucosally reduced inferior turbinate. Lateral pressure was applied during this process to fracture the turbinate away from the septum with a freer elevator along the length of the entire inferior turbinate with surgical guidance provided by endoscope. Hemostasis was achieved with cautery. The surgeon stated that this documentation supports 30140, but our coding team believes that this aligns more with 30802. Which is correct? AAPC Forum Participant Answer: In this situation, the surgeon is correct as the note supports 30140 (Submucous resection inferior turbinate, partial or complete, any method). That’s because there is clear documentation the surgeon removed tissue, which is necessary before the turbinate bone can be removed. While 30802 (Ablation, soft tissue of inferior turbinates, unilateral or bilateral, any method (eg, electrocautery, radiofrequency ablation, or tissue volume reduction); intramural (ie, submucosal)) also describes a surgical procedure on the inferior turbinate, the descriptor notes tissue volume is reduced rather than removed to open up the airway. Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC
