Pediatric pt brought into DSG for:
Pre and Post Op Dx: Recurrent Epistaxis
Px: Nasal Endoscopy with Cautery
Description:
‘… The nasal passages were examined with a 0-deg endoscope. There were no masses or lesions noticed on either side as far distal as the adenoid pad. There were enlarged vessels anteriorly on both sides of the septum. These vessels were cauterized with topical silver nitrate. Bacitracin was applied to cauterized areas. This concluded surgery. …’
I coded 31238-50-endoscopy with control of nasal hemorrhage. An Auditor is recommending 31299- unlisted, Because there is no active bleeding stated.
Does the 31238 require the bleeding to be current? Or does the simple fact that the pt has had multiple nose bleeds in the past account for the need for surgery.
Other coding suggestions? 31231 with 17250?
Thanks for the help,
Gina