Otolaryngology Coding Alert

Coding Challenge:

Nasal and Sinus Endoscopies: Case Study Helps Simplify A Potential Knotty Undertaking

Published on Thu Jun 16, 2011

Don't forget: Apply 150 percent adjustment for bilateral procedures when calculating revenue.

Many coders think that coding functional endoscopic sinus surgery (FESS) is a tricky business --and with good reason. FESS is not just one operation, but rather a series of diagnostic and treatment procedures that ENTs perform with the help of rigid nasal endoscopes. However, many patients who undergo FESS will only need diagnostic procedures, not a surgical functional operation.

If FESS continues to give you a hard time, the following case study could boost your confidence for distinguishing diagnostic from surgical procedures.

The challenge: Examine this sample operative note, and then compare your answers to the solution from our experts.

Preoperative diagnoses
1. Chronic sphenoid sinusitis
2. Chronic maxillary sinusitis
3. Chronic frontal sinusitis
4. Chronic ethmoid sinusitis
5. Nasal cavity polyp
Postoperative diagnoses:
1. Chronic sphenoid sinusitis
2. Chronic maxillary sinusitis
3. Chronic frontal sinusitis
4. Chronic ethmoid sinusitis
5. Nasal cavity polyp
Procedures performed:
1. Bilateral sinus endoscopy with sphenoidotomy and removal of tissue from the sphenoid sinus
2. Sinus endoscopy with frontal sinus exploration, bilateral
3. Sinus endoscopy with total ethmoidectomy, bilateral
4. Sinus endoscopy with maxillary antrostomy and removal of tissue from the maxillary sinus bilaterally
5. Stereotactic computer assisted surgery
Anesthesia: General endotracheal anesthesia
Estimated blood loss: 300 mL
Specimens: Bilateral ethmoid sinus contents
Brief history:
The patient is a 74-year-old gentleman with a history of bilateral nasal congestion and history of chronic sinusitis. Examination in the office revealed bilateral nasal polyposis. Decision was made to take him to the operating room for functional endoscopic sinus surgery with removal of polyps. Risks and benefits were explained to the patient, he agreed to proceed.
Details of procedure:
The patient came to the operating room, was placed in supine position on the operating room table. General face mask anesthesia was given until a deep plane of anesthesia was obtained. At that point, an endotracheal tube was placed by the anesthesiology service without difficulty.
Approximately 10 mL of one percent lidocaine with 1:100,000 epinephrine was injected into the middle turbinate, septum and polyps bilaterally. Afrin-soaked pledgets were placed. To allow time for anesthesia and decongestion, the patient's LandmarX CT scan was then loaded on the LandmarX device, The head device was then secured to the patient's forehead. Point to point discrimination was then performed with a high degree of accuracy. The patient was then prepped and draped in routine fashion. Surgery began with a 0 degree nasal endoscope and a 4 mm straight shot microdebrider. Polyps which were filling the entire left nasal cavity were debrided from inferiorly to superiorly. The middle turbinate was identified and polyps were completely removed from the middle meatus. The uncinate was then infractured with a sinus seeker.
A back biter was then used to perform a Parsons window. A straight shot microdebrider was then used to take down the uncinate, all the way to the inferior turbinate and superiorly to the middle turbinate. A large maxillary antrostomy was then performed on the left maxillary sinus with a 0 degree straight shot microdebrider. A 40-degree microdebrider was then used to remove polypoid disease from the left maxillary sinus. The ethmoid bulla was then taken down with a 0 degree microdebrider, A large window was then made into the basal lamella, into the posterior ethmoids. Polypoid material and debris were removed from the posterior ethmoids, back to the anterior face of the sphenoid and laterally to the lamina papyracea. A large sphenoidotomy was then performed with a StraightShot microdebrider, just medial and inferior to the superior turbinate, This inferior half of the superior turbinate was resected with the StraightShot microdebrider, Polypoid tissue was then removed from the sphenoid sinus with the rnicrodebrider. The 40-degree microdebrider was then used to remove polypoid tissue from the frontal recess and up into the left frontal sinus. No further evidence of polyps were identified within the left sinuses. Polypoid tissue was removed medial to the middle turbinate with a 0 degree StraightShot microdebrider. Afrin soaked pledgets were then placed in the left nasal cavity. Attention was then turned towards the right nasal cavity. Again, using a 0-degree endoscope and a StraightShot microdebrider, polypoid tissue was removed from the floor of the nasal cavity, superiorly medial to the middle turbinate, up to the cribriform plate. The middle turbinate was then medialized and polypoid tissue was removed from the middle meatus. The uncinate was then infractured with a sinus seeker and a Parsons window was created with the back biting forceps. StraightShot microdebrider was then used to remove the uncinate in its entirety from the inferior turbinate, superiorly to the middle turbinate.
A large maxillary antrostomy was performed on the right side with a 0 degree microdebrider. Polypoid tissue from within the maxillary sinuses were removed with the 40 degree microdebrider. The ethmoid bulla was then taken down with the StraightShot microdebrider and a large window was created through the basal lamella, into the posterior ethmoids. Polypoid material was removed from the posterior ethmoids, from the skull base laterally, to the lamina papyracea and inferiorly maintaining an inferior basal lamellar strut. The sphenoid sinus was then entered and large sphenoidotomy was created, and then the StraightShot microdebrider was used to remove polypoid tissue from the right sphenoid sinus. A 40-degree microdebrider was then used to remove polyps from the right frontal recess, up into the right frontal sinus. Afrin soaked pledgets were then placed. Image guidance was used throughout this entire case to help localization of the skull base, the optic nerve and the sphenoid sinus. The Afrin soaked pledgets were then removed and then Gelfoatn with. Kenalog 40 was placed into the posterior ethmoids, sphenoid sinus, anterior ethmoids and frontal recess bilaterally. Surgifio was then placed in the maxillary sinuses and the remaining tissue for hemostasis. The nasopharynx was then suctioned free of blood products, there was no further evidence of bleeding. At that point, the procedure was completed. The patient was awoken from general anesthesia, extubated and sent to anesthesia care unit in stable condition.

Filter Out Redundant Procedures

First, you should notice that all procedures in the op note sample were bilateral, which means you should append modifier 50 (Bilateral services) to your CPT^®s. Next, you would perhaps consider coding 30115 (Excision, nasal polyp[s], extensive) or 31237 (Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement [separate procedure]) for the endoscopic removal of polyps. Right? Wrong. The purpose of the polyp removal in this example was for better visualization and access, so 30115 or 31237 would not apply.

Leave 31255, 31267, 31276, 31288 Intact In Your Claim

After identifying what codes would not be necessary, you should be able to identify the remaining procedures as significant to your claim. For our case, these are:

31276 (Nasal/sinus endoscopy, surgical with frontal sinus exploration, with or without removal of tissue from frontal sinus) for frontal recess scope;

31255 (Nasal/sinus endoscopy, surgical; with ethmoidectomy, total [anterior and posterior]) for FESS with total ethmoidectomy;

31267 (Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus) for maxillary antrostomy with removal of tissue; and

31288 (Nasal/sinus endoscopy, surgical, with sphenoidotomy; with removal of tissue from the sphenoid sinus) for sphenoid sinusoscopy;

+61782 (Stereotactic computer-assisted [navigational] procedure; cranial, extradural [List separately in addition to code for primary procedure]), the add-on code for stereotactic guidance.

Don't forget to append modifier 50 to these CPT^®s to describe bilaterality, except 61782.

Calculation: Under the 2011 Fee Schedule, 31276 should pay about $517.12 national rate (15.22 RVUs multiplied by the 2011 conversion factor of 33.9764); $409.76 national rate for 31255 (12.06 RVUs multiplied by 33.9764); $324.81 national rate for 31267 (9.56 RVUs multiplied by 33.9764); $275.89 national rate for 31288 (8.12 RVUs multiplied by 33.9764); and $198.76 national rate for 61782 (5.85 RVUs multiplied by 33.9764).

Here's how you should calculate the total revenue for your claim: Take each national rate you calculated, multiply by 1.5 for each bilateral procedure. Then, divide each procedure by two or multiply by 0.5 (50 percent). Do not multiply 31276 by 0.5 (50 percent) because it is a primary surgery; 61782 by 0.5 (50 percent) because it is an add on procedure and modifier 51 exempt. This should give you a total of about $1,733.79 for revenue.

Note: You can bill all of the procedures at full fee (times two for bilateral) and let the payer reduce the fees for multiple procedures.

Caution: Not every FESS code requires add-on codes 61782, says Claudia Stephens, CPC, at ENT for Children PA in Coppell, Texas. Do not code 61782 unless the guidance is medically necessary and appropriately documented in the operative note. In which case, your documentation should include at least one of these reasons:

disease abutting the skull base, orbit, optic nerve or carotid artery;

cerebrospinal fluid rhinorrhea (349.81) or conditions where there is a skull-base defect;

benign (212.0) and malignant sino-nasal neoplasms;

revision sinus surgery;

distorted sinus anatomy of development, postoperative, or traumatic origin;

extensive sino-nasal polyposis;

pathology involving the complex posterior ethmoid, frontal and sphenoid sinuses.

Seal Your Claim With Appropriate Diagnosis Links

For your diagnoses, you should link the following codes accordingly:

473.1 (Chronic frontal sinusitis) linked to 31276-50;

473.2 (Chronic ethmoidal sinusitis) and 471.0 (Polyp of nasal cavity) linked to 31255-50;

473.0 (Chronic maxillary sinusitis) linked to 31267-50