Otolaryngology Coding Alert

Give your sinus and turbinate coding skills a test.

When approaching any claim, the trick is to know the lingo as well as bundling/unbundling rules. See if your turbinate coding is up to par by coding the following operative report:

The otolaryngologist began surgery using bipolar forceps to cauterize the inferior and medial borders of the inferior turbinate. He then gently in-fractured the middle turbinate and using the backbiting forceps amputated the inferior one-third of the uncinate process. He identified the natural ostium of the maxillary sinus and connected it with an accessory ostium that was inferior to it. It was extended posteriorly into the fontanel of the middle turbinate. The bulla ethmoidalis was exonerated using the Weil-Blakesley forceps. A Merocel nasal tampon was trimmed to an arrowhead shape and placed in the anterior middle meatus to prevent lateralization of the middle turbinate.

The otolaryngologist wants to charge for an:

• extramural cautery of the right inferior turbinate
• endoscopic right nasal antral window
• endoscopic right anterior ethmoidectomy.

Encourage Using CPT Terms

Coding the above op report is especially challenging, says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J. "It’s hard to know exactly what the surgeon did because he uses terminology that we don’t see in CPT." For instance, it’s not clear where he used the scope. Additionally, the body of the operative note does not indicate which sinus, right or left, is being worked on.

A major stumbling block is the description of "endoscopic right nasal antral window." You have to do antrotomy (incision through the wall of an antrum) to make a nasal antral window.

Clearer way: Documentation for a nasal window usually describes enlarging the antrotomy in all directions and talks about tucking flaps. But it is probably common to use the terms "nasal antral window" and "antrotomy" interchangeably.

Code it: The op report’s listing of "endoscopic right nasal antral window" is really an antrostomy (the surgical formation of an opening into an antrum) of the maxillary sinus, Cobuzzi says. Report the procedure with 31256 (Nasal/sinus endoscopy, surgical, with maxillary antrostomy).

Report Ethmoidectomy, Destruction

You should code two additional procedures.

1. Ethmoidectomy: For the endoscopy of the right anterior ethmoid, assign 31254 (Nasal/sinus endoscopy, surgical; with ethmoidectomy, partial [anterior]).

2. Destruction: Code the extramural cautery of the right inferior turbinate with 30802 (Cautery and/or ablation, mucosa of inferior turbinates, unilateral or bilateral, any method; intramural).

Include Excision With FESS

The otolaryngologist was correct not to list the excision of the middle turbinate as a reportable procedure. Although the op note says the otolaryngologist "in-fractured the middle turbinate" and "amputated the inferior one-third of the uncinate process," this procedure is bundled with the ethmoidectomy and maxillary functional endoscopic sinus surgery (FESS) codes.

Reason: Middle turbinate surgery is is considered as a way of gaining access to the ethmoid and maxillary sinuses.

Exceptions: There are only three times when middle turbinate surgery is not considered access and is thus billable:

1. You can charge for middle turbinate surgery if an otolaryngologist performs it alone. In this case, CPT instructs you to bill the 30999 unlisted-procedure code of the nose.

2. If an otolaryngologist performs middle turbinate surgery in addition to sinus surgery on the frontal or sphenoid sinus, but not on the ethmoid or maxillary sinuses, you can bill 30999 (Unlisted procedure, nose) in addition to 31276 (Nasal/sinus endoscopy, surgical with frontal sinus exploration, with or without removal of tissue from frontal sinus) and / or 31287-31288 (Nasal/sinus endoscopy, surgical, with sphenoidectomy …). "Middle turbinate surgery is not considered access to the frontal or sphenoids," Cobuzzi says.

3. Middle turbinate surgery (30999) is also separately billable when done in addition to septoplasty (30520, Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft) with no FESS, Cobuzzi adds.

Summary: No edits exist for the ethmoidectomy (31254), maxillary antrostomy (31256) and cautery (30802). List the codes in descending value order starting with the code containing the most relative value units. Designate additional codes as multiple procedures with modifier 51 (Multiple procedures).