A surgeon begins an endoscopic procedure intending to examine the patient's maxillary and ethmoid sinuses only. Upon examination during this procedure, the surgeon determines the patient's symptoms will be effectively treated by removing some inflamed tissue from the maxillary sinus. The surgeon removes the tissue from the maxillary sinus, removes the endoscope and the procedure concludes. The coder may select:

Question

Quizplus · Accepted Answer

The correct code is 31267 because it specifically describes a surgical endoscopy with maxillary antrostomy and removal of tissue from the maxillary sinus, which matches the procedure performed. Code 31231 is for a diagnostic endoscopy, which was not the primary intent of the procedure once the surgeon decided to remove tissue. Codes for diagnostic procedures are generally not reported in addition to codes for surgical procedures when performed in the same area during the same session.

A Surgeon Begins an Endoscopic Procedure Intending to Examine the Patient's