Otolaryngology Coding Alert

Hint: Ethmoidectomy may occur without an endoscope — but it’s rare.

If you come across documentation of an ethmoidectomy, you need to know several important facts before you can code your claim. To ensure that you’re up to speed on how to report these procedures, check out the answers to five essential FAQs.

Q: How Many Codes Exist for Ethmoidectomies?

A: Otolaryngologists perform ethmoidectomies to remove infected tissue, bone, or polyps in the ethmoid sinuses. Since ethmoid sinuses are divided into anterior and posterior regions, CPT^® has two separate codes for reporting endoscopic surgical ethmoidectomies:

• 31254 (Nasal/sinus endoscopy, surgical with ethmoidectomy; partial (anterior))
• 31255 (… with ethmoidectomy; total (anterior and posterior)).

You’ll also find additional codes if the surgeon also works on other sinuses along with the anterior and posterior ethmoid sinuses, says Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, CMCS, of CRN Healthcare in Tinton Falls, New Jersey. In these situations, one of these combination endoscopic sinus surgery codes may apply, depending on what else the ENT performed:

• 31253 (Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including frontal sinus exploration, with removal of tissue from frontal sinus, when performed)
• 31257 (…total (anterior and posterior), including sphenoidotomy)
• 31259 (…total (anterior and posterior), including sphenoidotomy, with removal of tissue from the sphenoid sinus)

Q: How Do You Differentiate Between 31254 and 31255?

During an endoscopic partial (anterior) ethmoidectomy (31254), the physician uses an endoscope to enter the anterior portion of the nasal cavity, which is up toward the frontal sinuses. Once the endoscope is in place, the otolaryngologist identifies the ethmoid bulla, opens it, and resects it with cutting forceps.

As part of a 31254 service, the otolaryngologist will likely remove the anterior cells as well. The otolaryngologist may also look up into the frontal sinuses while in the anterior ethmoid sinuses in order to determine the condition of the frontal sinuses, and evaluate whether further surgery is needed in that area.

During a total (anterior and posterior) ethmoidectomy (31255), the otolaryngologist opens the ethmoid sinuses and removes the diseased and loose bony partition from the lamella papyracea in addition to the ethmoid bulla found in the anterior ethmoid sinuses.

Q: Can the Physician Perform an Ethmoidectomy Without an Endoscope?

A: Yes, but this would be quite rare. The physician might also use an open intranasal approach during the procedure, which will change your coding choices. If the physician doesn’t use an endoscope during anterior surgery, and instead opts for an open intranasal approach, code 31200 (Ethmoidectomy; intranasal, anterior). If the posterior and anterior cells require surgery and the physician uses an open intranasal approach, code 31201 (… intranasal, total).

More info: During the service described by 31200, the physician makes an intranasal incision to gain access into the anterior ethmoid sinus. The provider then removes all diseased contents from the anterior ethmoid sinus. In 31201, the provider uses an intranasal approach to access the anterior and posterior ethmoid sinuses and removes the diseased contents.

Best bet: Check ethmoidectomy encounter notes to ensure endoscope use. “If you see no evidence of an endoscope, it is recommended that the surgeon be queried if they forgot to mention the endoscopic approach in the operative note, since it is very rare that an open intranasal approach to an ethmoidectomy is ever performed,” Cobuzzi says. “If an endoscope was not used, it’ll likely narrow your code choices to 31200 or 31201.” Since the development of functional endoscopic sinus surgery, however, physicians rarely perform open intranasal sinus surgeries. Physicians only use these procedures if there is a condition that they cannot treat via the endoscope.

Q: What Constitutes a Total Extranasal Ethmoidectomy?

A: In the rare event that your otolaryngologist performs a total extranasal ethmoidectomy, you’ll choose 31205 (Ethmoidectomy; extranasal, total) for the procedure.

During a total extranasal ethmoidectomy, the physician accesses the ethmoid sinus through external approach, requiring an incision made through the face, between the nasal dorsum and medial canthus of the eye and carried down to the medial orbital bone to expose the sinus cavity. The physician then removes any diseased tissue, adds packing, and closes the incision.

As previously stated, however, these ethmoidectomies are barely ever performed by otolaryngologists.

Due to improved technology, external ethmoidectomy is infrequent, and has been replaced by endoscopic ethmoid sinus surgery.

An otolaryngologist may perform an extranasal ethmoidectomy when special circumstances exist. Some of these special circumstances include patients with:

• Massive facial trauma,
• Acute orbital infections,
• Acute bacterial sinusitis, or
• Severe arterial nosebleeds.

As rare as an open intranasal ethmoidectomy is, you will find that an open extranasal ethmoidectomy is even rarer. If you think you have a 31205 claim on your hands, be sure to check with the provider before filing the claim.

Q: What Might an Open Intranasal Ethmoidectomy Op Note Look Like?

A: Check out this sample op note — you might see similar language in your otolaryngologist’s ethmoidectomy op notes:

CC: Sinus drainage, sinus pain CT scan revealed chronic ethmoidal sinusitis

History: Medical management has been unsuccessful; therefore we are going to perform an intranasal ethmoidectomy.

Procedure: The patient is appropriately prepped and anesthetized. I made an intranasal incision to gain access to the middle turbinate. I then partially resected the middle turbinate to remove obstruction. I then inserted a curette to break into the anterior cells of the ethmoid sinus. I removed the diseased contents of the anterior ethmoid sinus drainage commenced. I then packed the nasal area with gauze. No complications.

Coding: For this encounter, you’d report 31200 with J32.2 (Chronic ethmoidal sinusitis) appended to represent the patient’s sinusitis.