Nasal polyps are noncancerous, teardrop-shaped growths that form in the lining of the nasal passages or sinuses, often resulting from chronic inflammation. These masses can obstruct airflow, leading to congestion, reduced sense of smell, and recurrent sinus infections. When conservative treatments are ineffective, surgical removal is necessary to restore normal breathing and sinus function. The procedure must be accurately translated into a standardized language for billing and medical record-keeping using Current Procedural Terminology (CPT) codes. These codes provide a uniform system used by healthcare providers to describe medical procedures and services to insurance payers.
The Specific Code for Extensive Removal
The CPT code designated for the extensive excision of nasal polyps is 30115, titled Excision, nasal polyp(s), extensive. This code is used when the surgical effort significantly exceeds that of a routine, minor procedure, accounting for the complexity and time involved in addressing a large burden of polyps. The use of 30115 implies a non-endoscopic approach, meaning removal is typically performed using instruments like a snare or forceps under direct visualization, without a fiberoptic scope. Due to the resources and anesthesia required, the procedure is often performed in a facility setting, such as an outpatient hospital or ambulatory surgical center. This code is reported once per operative session, regardless of the number of polyps removed, as it encompasses the entire extensive effort.
Differentiating Extensive vs. Simple Procedures
The choice between the extensive CPT code (30115) and the simple code, 30110 (Excision, nasal polyp(s); simple), depends on the documented surgical effort and the scope of the disease. Simple excision (30110) involves removing one or a few easily accessible polyps, typically performed in an office setting with minimal anesthesia. Excision is considered extensive (30115) when polyps are numerous, diffuse, or extend deeper into the nasal passages toward the sinus openings. The distinction relies on the overall surgical time, risk, and complexity required for complete removal, not just the polyp count. Procedures requiring specialized instruments or significant manipulation to clear the nasal passages are generally coded as extensive.
Necessary Documentation and Associated Coding Rules
Documentation Requirements
Accurate documentation is necessary for justifying the extensive excision code 30115. The operative report must explicitly describe the extent of the polyp burden, noting the specific anatomical locations and the non-endoscopic technique used. Detailed notes should specify that the effort exceeded a simple office procedure, perhaps by mentioning the involvement of multiple quadrants of the nasal cavity or the use of specific surgical tools.
Endoscopic Procedures
If an endoscope is used as the primary surgical tool to see and remove the polyps, the correct code is 31237 (Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement), not 30115. Non-endoscopic codes (30110 and 30115) should not be reported when removal is performed with an endoscope. Diagnostic nasal endoscopy (CPT code 31231) is typically considered a bundled component of any more comprehensive surgical procedure and cannot be billed separately alongside 30115 or 31237.
Bilateral Procedures
When the extensive excision is performed on both the left and right nasal passages during the same session, the procedure is considered bilateral. To indicate this, the surgeon reports CPT code 30115 with the addition of Modifier 50 (Bilateral procedure). Modifier 50 signals to the payer that the procedure was performed on a paired organ, resulting in a payment adjustment, typically 150% of the allowed fee for a unilateral procedure.