# Nasal Endoscopy wtih sinusotomy



## dyoungberg (Jan 31, 2013)

I would normally bill the operative report below as 31255,31256,31288,31276-50.  Recently someone told me to bill as 31090, 31255, & 31256-50.  I don't believe this is correct.  When would the use of 31090 be appropriate?  Any thoughts, comments are appreciated.

_PREOP DIAGNOSIS:    
1. CHRONIC MAXILLARY SINUSITIS
2. CHRONIC ETHMOID SINUSITIS
3. CHRONIC FRONTAL SINUSITIS 
4. CHRONIC SPHENOID SINUSITIS 
5. SINONASAL POLYPOSIS 
6. BONY NASAL SEPTAL SPUR WITH OBSTRUCTION 

POSTOP DIAGNOSIS:   SAME  

PROCEDURE:     
1. BILATERAL PRIMARY NASAL ENDOSCOPY WITH POLYPECTOMY 
2. BILATERAL PRIMARY NASAL ENDOSCOPY WITH MAXILLARY ANTROSTOMY AND REMOVAL OF TISSUE 
3. BILATERAL PRIMARY NASAL ENDOSCOPY WITH TOTAL ETHMOIDECTOMY 
4. BILATERAL PRIMARY NASAL ENDOSCOPY WITH FRONTAL SINUSOTOMY 
5. BILATERAL PRIMARY NASAL ENDOSCOPY WITH SPHENOID SINUSOTOMY 

COMPLICATIONS:   NONE 

ANESTHESIA:    GENERAL  

FINDINGS: Extensive sinonasal polyposis, several measuring more than 4.0 cm's. Stenotic maxillary, frontal and sphenoid ostium bilaterally. Left bony nasal septal spur with obstruction. 

INDICATIONS:  The patient presents with severe chronic sinusitis with obstruction, pain, congestion, inability to breathe through the nose. 

DESCRIPTION: With the patient appropriately identified in the preop holding area, he was taken to the OR and placed upon the OR table. General anesthesia was induced. The table was rotated 90 degrees. Lacrilube was applied to the eyes and the patient was prepped and draped in standard surgical fashion. Local anesthetic 1% Lidocaine with epinephrine was used to infiltrate the septal mucosa and lateral nasal wall. The left nasal cavity has partially prolapsing polyps. The left nasal cavity was first debulked of polyps via transnasal approach. Several more than 3.0-4.0 cm polyps were removed from the middle meatus. This allowed the left nasal cavity to be further visualized. A left hemi transfixion incision was made and a submucoperichondrial flap was raised for further exposure. The bony and septal junction was disarticulated with the D knife and a contralateral flap was raised. Double action scissors was used to take down the perpendicular plate of the ethmoid bone and deviated quadrangular cartilage. The quadrangular cartilage was then scored and put back into anatomical position. Removal of bony spur improved the exposure greatly. The hemitransfixion incision was closed with 4-0 chromic suture. Next the left middle turbinate was medialized. Several large polyps completely filled the middle meatus and these were all debulked with a straight Blakesley.  

The sinus seeker identified a completely stenotic maxillary ostium. The microdebrider was used to complete the uncinectomy and maxillary antrostomy removing polyps from the maxillary sinus. The ethmoid air cells were dissected completely starting with the ethmoid bulla extending posteriorly to the basal lamella using the micro debrider. The frontal recess was visualized and there is diseased polypoid mucosa present throughout. This was  dissected with upbiting Blakesley and micro debrider. A frontal sinus seeker was introduced into the frontal sinus. Next, the middle turbinate was lateralized and the sphenoid ostium identified and a polypectomy was completely, as well as sphenoid sinusotomy with the micro debrider staying medial and inferior. The left nasal cavity was packed with Afrin soaked neuro patties. 

Next, the contralateral side was visualized as well. The middle turbinate was medialized and large polyps completely filling the middle meatus were all debulked with a straight Blakesley. The micro debrider was then used to debulk the middle meatus. Next, a sinus seeker identified the maxillary ostium. A backbiter created the maxillary antrostomy and a micro debrider further used to enlarge the maxillary ostium and complete the uncinectomy. 
The ethmoid air cells were completely dissected with the micro debrider starting with the ethmoid bulla extending posteriorly to the basal lamella. The area was irrigated and suctioned dry. The frontal recess was then visualized with the 30 degree endoscope and diseased polypoid mucosa was debrided with the upbiting Blakesley, as well as the micro debrider. Medial to the middle turbinate the sphenoid ostium was identified with polypoid disease. This was debulked and sphenoid sinusotomy was completed. The area was then packed with Afrin soaked neuro patties. All the neuro patties were removed. The areas that were bleeding were cauterized with the suction Bovie and Surgicel used to pack the ethmoid cavities, and also MeroPack was placed. Doyle splints were secured in the nose with a transseptal 2-0 nylon suture. The nasopharynx was suctioned dry. 

The patient tolerated the procedure well. He was handed back to anesthesia and went back to the recovery room in good condition. _


Thanks very much!

Debbie, CPC-A
Billing Department
NW FL Surgery Center


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