Coding Nasal Endoscopy Procedures
A special study of Medicare Part B claims for diagnostic Nasal Endoscopy Procedures, showed that most improper payments were due to insufficient documentation.
The specific CPT(R) codes targeted in the study were:
? 31231 Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure)
? 31233 Nasal/sinus endoscopy, diagnostic with maxillary sinusoscopy (via interior meatus or canine fossa puncture)
Codes 31231-31235 include inspection of the interior nasal cavity, middle and superior meatus, turbinates, and spheno-ethmoid recess.
Documentation Checklist
Medicare administrative contractors require four essential elements to be documented in the medical record, to process a claim for nasal endoscopy:
? The correct date of service
? The reason for the procedure
? The results of the procedure
? The physician or other qualified healthcare professional?s signature (and/or signature log, or attestation)
Within that documentation there must be evidence of medical necessity, supported by the associated diagnosis codes.
According to the American Rhinologic Society (ARS) common indications for diagnostic nasal endoscopy include, but are not limited, to:
? Evaluate for chronic sinonasal symptoms unexplained by anterior rhinoscopy.
? Assess interval response to medical or surgical therapy in patients with chronic sinusitis and recurrent acute sinusitis.
? Monitor for recurrence of nasal polyps.
? Evaluate and manage epistaxis.
? Perform endoscopically guided cultures.
? Assess facial pain suggestive of rhinogenic origin.
? Evaluate clear rhinorrhea suggestive of cerebrospinal fluid leak.
? Perform initial diagnosis and interval surveillance for sinonasal neoplasms.
If the claim doesn?t meet these requirements and is consequently denied, all is not lost. If one takes the time to correct the errors, you will be very well able to obtain or retain payment.
For example, if the submitted office note was partially illegible and not signed, submit a transcribed version of the documentation with the original version and an attestation from the provider.