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help please - Hello all

  1. Talking help please - Hello all
    Medical Coding Books
    Hello all,

    Procedure: Direct nasopharyngoscopy with nasopharyngeal biopsy

    Would this be unlisted rather 92511/42806?

    note reads:

    Using a 0-degree nasal endoscope, endoscopy was performed. The patient does have a slightly deviated nasal septum towards the left side, making it more advantageous to operate through the right nostril. The right inferior turbinate was outfractured with the Boies elevator. An Afrin-soaked pledget was placed along this to control some oozing from the mucous membrane. Using the 0-degree nasal endoscope and a 22-gauge spinal needle, we injected the nasopharyngeal tissue with 2 cc of 1% Xylocaine eith epinephrine. This looked like benign lymphatic tissue with a sulphur granule in the center, which may explain the increased metabolic activity on the PET scan. Representative biopsies x2 were then taken. Using a Bovie cautery at a setting of 20, this tissue was cauterized to ensure there was no bleeding. We were in the midline and well away from the area of the eustachian tubes. Once this was completed, there was not active bleeding.


  2. #2
    Albany, New York
    Hi Jamie......

    Unfortunately, this has to be coded as "Unlisted" (42999)....

    Your suggestion would not be appropriate because the biopsy was done via the scope.
    Therefore the approach would be the first consideration, and would have to be coded with only one CPT for the procedure.

    Also, the description of CPT 42806 in Coders Desk Reference does not indicate the use of a scope, and your procedure note does not indicate this was an "open" procedure.

    Hope this helps.......
    Karen Maloney, CPC
    Data Quality Specialist

  3. Default
    Thanks Karen for your help and have a nice day!

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