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ENT help - This one has be stumped

  1. Question ENT help - This one has be stumped
    Medical Coding Books
    Hello all,

    This one has be stumped and wanted some thoughts.....

    Op note reads:
    Procedure Performed:
    1. Nasal endoscopy
    2. Outfracture of right inferior turbinate
    3. Biopsy x3 of naspharyngeal mass

    nasal endoscopy was performed. The right inferior turbinate was hypertrophic and causing some encroachment on the airway which would hamper biopsy. This was therefore outfx using a Boise elevator.

    We then used 18 gauge spinal needle to inject about 1cc of 1% Xylocaine with epinephrine into the nasal pharyngeal tissue. There was a lobulated mass just medial to the eustachian tube area and coming from Roseenmuller's fossa on the right side. This was asymmetrical and correlated with the increased PEF scan activity. After vasoconstriction, mulltiple biopsies of this were taken using a true-cutting forceps.

    Path came back (???)
    Collision tumor between nasopharyngeal carcinoma and extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT LYMPHOMA)

    31231 Endoscope, 30930 fracturing, and 42804 once since not different mass/or lesion
    DX 147.9, 200.31


  2. #2
    Is this biopsy being performed via endoscope? That's what it looks like. If that is the case, it codes out to 42999 (Unlisted procedure, pharynx, adenoids, or tonsils).

    I would query the physician to find out for certain. But if it was endoscopic, the codes would be:

    Chastity Nault, CPC
    HIM Professional Services Coder - Remote

  3. Default
    thanks! Have a good weekend!

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