That was denied by the insurance when medical records were sent. Bony edges isn’t tissue so I’m trying to find another code but want to confirm if 31020 is the best code.Have you looked at (endoscope was used) 31267-RT? Since 'tissue' (bony edges) was also removed.
Exactly, I have no idea what he means either and this provider is not very responsive so I doubt I will ever get an answer. However; the entire report is there image 5963 is page 1, image 5964 is page 2, image 5965 is page 3. This was sent to UHC for a claim 30930, 61782, 30520, along with 31267. Initially the 30520 and 31267 was denied so I sent the op report and CT for 30520 was a necessary procedure due to septal deviation causing 75%-100% nasal airway obstruction. 31267 was medically necessary as CT Sinus shows right maxillary sinus opacification with soft tissue density with chronic osteitis. So they went back and paid 30520 but states the 31267 was not medically necessary. My supervisor (not a coder) says to bill a 31256, and if I've sent the medical records and UHC is still saying the 31267 is not medically necessary how do I respond to that appeal denial?I would need to read the rest of the operative note to comment on what you are looking for. I do not code from the ”surgeries performed” or from the findings. It looks like the Endoscopic concha bullosa removal was actually left off the list of surgeries performed. That would be 31240 in addition to the 31267 and the inferior turb outfracture. And dont forget the stereotactic guidance. I have no idea what your surgeon is referring to where it says at the bottom of the note where it says “the boney edges were then resected and the mucosa was.....” I need the next page and I think that you perhaps need to ask your surgeon what boney edges is he/she referring to and perhaps he needs to dictate a revised operative note to clarify confusion since the “boney edges” of what specifically are not listed.
Thank you so much for your help!! I will reach out to the doctor and see if he will make time to do this.Whenever you have a medical necessity dispute, you need to get the doctor involved. You need to set up a call with UHC saying that maxillary silent sinus syndrome is not medically necessary with your doctor and you need him/her to explain what silent sinus syndrome is and how it is made better via a maxillary antrostomy with removal of tissues. There is a good chance that UHC only has sinusitis diagnoses as medically necessary and silent sinus syndrome is not understood by them.