# 1.	Endoscopic sinus surgery with bilateral revision maxillary antrostomy



## LaceyCanon (Apr 9, 2019)

Can someone review this operative report and see if it is appropriate to bill 31255 for the right side?

POSTOPERATIVE DIAGNOSES:
1.	Chronic bilateral ethmoid and maxillary sinusitis.
2.	Recurrent nasal polyposis.
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PROCEDURE PERFORMED:
1.	Endoscopic sinus surgery with bilateral revision maxillary antrostomy with removal of tissue from the right maxillary sinus.
2.	Endoscopic sinus surgery with bilateral nasal polypectomy.
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INDICATIONS:
The patient is a 45-year-old gentleman with history of chronic sinusitis and recurrent nasal polyposis.  He has had worsening symptoms of nasal congestion and exam in clinic as well as a repeat CT scan revealed extensive opacification of the ethmoid and maxillary sinuses with recurrent nasal polyps.  The patient was subsequently scheduled for the above procedures.
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FINDINGS:
Intraoperative findings revealed extensive polyps throughout the ethmoids and middle meatal regions bilaterally.  There were polyps and thick mucus within the right maxillary sinus.  There was extensive scarring of the right middle turbinate, scarring to both the lateral nasal wall as well as the septum.
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DESCRIPTION OF PROCEDURE:
After informed consent was obtained, the patient was taken to the operating room and placed on the operating table in supine position.  After adequate general endotracheal anesthesia was induced, the patient was placed in a slightly head up position and the nasal cavities were packed with Afrin-soaked pledgets bilaterally.  The patient was prepped and draped in usual sterile fashion and the operation was begun by using a zero-degree endoscope to examine nasal cavities bilaterally.  The preoperative CT scans were then removed.  Attention was turned to the right side where the polyps emanating out of the middle meatal region were visualized and several biopsies were taken with thru-cut forceps.  The microdebrider was then used to remove the polyps into the middle meatal region.  The middle turbinate was essentially involved and a large block of scar tissue between the lateral nasal wall and the septum.  The majority of the middle turbinate was removed with removal of the scar tissue.  Once this was opened, the anterior and posterior ethmoid cells could be easily visualized and the polypoid mucosa throughout the ethmoid was removed with the microdebrider.  The maxillary ostium was scarred shut and using a curved ball-tipped seeker, the scar tissue on the lateral nasal wall into the maxillary sinus was opened.  The microdebrider was then used to enlarge this antrostomy and the sinus was filled with thick inspissated mucus as well as several large polyps.  Using a 120 degree curved microdebrider blade, the polyps within the sinus were removed.  An Afrin-soaked pledget was then placed in the dissected field and attention was turned to the left side.  The polyps within the middle meatal region were 1st biopsied and then removed using the microdebrider.  There was not as extensive scarring of the middle turbinate.  The polyps within the previous ethmoidectomy site were removed and then the scarred maxillary ostium was probed with a curved ball-tipped seeker to create a new opening and then the scar tissue was removed with the microdebrider.  The left maxillary sinus did not have any polyps located within the sinus.  The microdebrider was then used to remove any polyps within the superior meatal region bilaterally and then an Afrin-soaked pledget was placed in the dissected field on the left side.  A Telfa pack coated in bacitracin was placed in the middle meatal regions bilaterally and the patient was returned to Anesthesia, awakened and taken to recovery room in stable condition.
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ESTIMATED BLOOD LOSS:
150 mL.
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COMPLICATIONS:
There were no complications.


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## feltskm (Apr 25, 2019)

*Agree*

Yes- they talk about removing tissue from the ethmoid sinus in the report portion.


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## b.cobuzzi (Jun 11, 2019)

You may want to request that your surgeon indicates the ”Surgeries Performed” in a more clear manner, listing everything that was performed on each side.  This appears to be a revision surgery. Although CTs were reviewed, it does not document that Stereotactic guidance was performed.  Had that been documented along with a revision surgery, 61782 would have been able to be billed. But the lack of documentation makes it so 61782 cannot be billed. Although we have to read the body of the operative note, the surgeon is taking a chance that their coder may miss a procedure or more, by not listing them all int he header.


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