Question

Code the diagnosis and procedure for the scenario where a mother brings a three-year-old boy for removal of nasopharyngeal polyps. The physician schedules the procedure for the operating room at the local hospital. Upon examination under anesthesia, the physician discovers that the procedure is a simple excision of three nasal polyps. What is the diagnosis and procedure code for this scenario?

Answer 1

The diagnosis code for the removal of nasopharyngeal polyps in a three-year-old boy is likely ICD-10-CM J33.9. The procedure code for a simple excision of three nasal polyps is CPT 30130. Accurate coding depends on the operative report and the provider's documentation.

Step-by-step explanation:

The diagnosis for a three-year-old boy undergoing removal of nasopharyngeal polyps is typically coded using the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM). The appropriate diagnosis code for nasopharyngeal polyps would likely be J33.9, which stands for Nasal polyp, unspecified.

The procedure code for the excision of nasal polyps is established by the Current Procedural Terminology (CPT) coding system. In this scenario, where simple excision of three nasal polyps is performed, the procedure could be coded as 30130 (Excision of nasal polyp(s); simple). This procedure code represents a simple excision of nasal polyps under anesthesia.

It is essential always to verify the exact procedure performed and any additional details provided in the operative report to select the most accurate CPT code. Moreover, the coding could vary based on specific details of the procedure or the healthcare provider's documentation.