Wiki 31231 documentation

[wynonna]

Hello:
Can anyone tell me the areas in the nose that need to be documented in order to code 31231? I've seen documentation without the turbinates mentioned in the procedure note section. Does this require a mod 52 or can it be billed without one? For an office visit.

 

[lgardner]

per EncoderPro (emphasis added by me):

Diagnostic evaluation refers to employing a nasal/sinus endoscope to inspect the interior of the nasal cavity and the middle and superior meatus, the turbinates, and the sphenoethmoid recess. Any time a diagnostic evaluation is performed, all these areas are inspected, and a separate code is not reported for each area. If all these areas are not fully inspected because it is deemed clinically unnecessary or due to an altered clinical presentation, it may be appropriate to append modifier 52 if no repeat examination is planned. If a repeat examination is planned, modifier 53 may be appropriate. Topical vasoconstrictive agents and local anesthesia are not reported separately. It is inappropriate to report supplies when these services are performed in an emergency room. For physician offices, supplies may be reported with the appropriate HCPCS Level II code. Check with the specific payer to determine coverage.