Manders21

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I want an opinion on this report. Doctor did an endoscopic repair of right choanal atresia with posterior septectomy and outfracture of inferior turbinates. I have the whole report below and I have the cpt codes that I need. But the part about the septectomy is where I have a question, do I need to have the doctor go into more detail? Or can I still bill for the septectomy based on the small information given?

Patient was taken to surgery induced with general anesthesia and intubated. Shoulder roll was placed to provide neck extension. Patient was then properly prepped and draped. Image guidance with medtronic fusion system was set in place and noted to be working appropriately with the patient's CT scan. This was used throughout the procedure. Bilateral nasal endoscopy was performed using a 0 degree endoscope. On the left there was no pathology. On the right there was evidence of membranous and boney choanal atresia. Afrin and epi pledgets were used to decongest the nose and for hemostasis.

Using a navigation suction, the posterior nasopharynx was entered on the right side by popping through the obstructive tissue and then bone. A microdebrider and drill were used to further remove the obstructive tissue and bone and to widen the opening into the nasopharynx. A microbackbider was used to perform a posterior septectomy to further open the posterior nasopharynx. A boise elevator was used to outfracture and lateralize the inferior turbinates. A propel drug eluting stent was placed in the posterior choana/area of septectomy to stent this area open.

At this point the procedure was complete. Any additional bleeders that were encountered were controlled with afrin pledgets. All instrumentation was removed and patient was sent to recovery in satisfactory condition.
 
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Manders21

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What codes do you have for this, Manders21?
Is there a better code to use for the septectomy? My book shows 30520 but online there is some conflicting information. Some say code 30520 and some say 31237. Do you recommend using either of those codes? Or do you think the endoscopic repair of the choanal atresia includes a septectomy?
 

b.cobuzzi

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30520 is not a septectomy, it is a septoplasty. 31237 is for a biopsy, polypectomy or debridement. The doctor is down in the nasopharynx, but there are no other codes for removal of abnormal tissue via endoscope. You might want to code 31237 with a 22 modifier to account to the additional difficulty from the procedure. The MUE (medically unlikely edits( for 31237 is only one a day, so you code this code no matter how many lesions are removed.
 
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