Otolaryngology Coding Alert

Sometimes a code's wording can leave just enough gray area to throw a coder off.

For instance, take 31267 (Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus). The phrase "removal of tissue" sounds like a debridement.

But what if your physician removes a polyp or cyst from the maxillary sinus? There's no code that says "polyp removal" or "cystectomy" for that sinus. Can you still call on 31267, or would you have to rely on a lesser code like 31256 (Nasal/sinus endoscopy, surgical, with maxillary antrostomy)?

That was the discussion at Proliance Orthopedics and Sports Medicine where Kristi Stumpf, MCS-P, CPC, COSC, ACS-OR, works. "If the surgeon removed a maxillary cyst but did not mention he removed diseased mucosa would you code 31256 or 31267?" she asked. "I searched and searched for source data and could not locate anything specifically addressing the allowance of 31267 for maxillary sinus polyp removal."

Let's take a look at the op note that raised Stumpf's question.

The patient presented with a long history of chronic sinusitis "that is typically refractory to medical management. His primary symptoms are nasal obstruction, significant pressure, and frequent infections," the op note says. The patient has heavy nasal polyps bilaterally and a deviated septum, the doctor notes.

Procedure: The physician started on the patient's left side. "The middle turbinate was removed on its anterior inferior half. Polyps were removed laterally and medially to the middle turbinate. The bulla ethmoidalis was opened up with a curet and polyps were removed in to the anterior ethmoid up in to the nasofrontal recess. The ground lamella was penetrated and the anterior wall of the sphenoid was identified. Septations of the ethmoid were broken up with the curet and polyps were removed from the sphenoid anteriorly following the roof of the sinuses. The natural maxillary antrostomy was identified. Polyps were removed superiorly and inferiorly with the Concept shaver and forceps. There was mucopurulence aspirated from the left maxillary sinus with suction. There was fairly heavy mucosal oozing. This was cauterized to obtain control."

Then the physician worked on the patient's right side. "The septum was so far deviated that the instruments could not be placed in to the nose. A right-sided hemitransfixion incision was made and the  submucoperichondrial flap was elevated. Just posterior to the caudal cartilage there was perpendicular plate of the ethmoid and vomer which was deviated over towards the right. This was removed."

The physician found out just how bad the polyps were. They "had pretty much replaced the middle turbinate. This was removed medially and lateral to the middle turbinate and portions of the polypoid changes of the middle turbinate were also removed with the Concept shaver. The anterior wall of the sphenoid was identified.

Following from posterior to anterior a curet and Concept shaver was used to remove the polyps and the ethmoid septations up in to the nasofrontal recess. The natural maxillary antrostomy was identified and widened. A superior and inferior uncinectomy was performed."

So what's going on here? First, let's look at the patient's diagnoses. The physician found four conditions that support medical necessity for the procedures:

• 473.0 -- Chronic sinusitis; maxillary

• 473.2 -- Chronic sinusitis; ethmoid

• 471.8 -- Other polyp of sinus; maxillary

• 470 -- Deviated nasal septum.

And here are the codes you'd report for this case:

• 30520 (Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft) supported by 470.

• 31255-50 (Nasal/sinus endoscopy, surgical; with ethmoidectomy, total [anterior and posterior]). You'd append modifier 50 (Bilateral procedure) to indicate the ENT worked on both ethmoid sinuses. Diagnosis code 473.2 supports this procedure.

• 31267-LT (Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus). You'd append Modifier LT (Left side) to help distinguish it from the next procedure, and support it with dx codes 473.0 and 471.8.

• 31256-59-RT (Nasal/sinus endoscopy, surgical, with maxillary antrostomy). Modifiers 59 (Distinct procedural service) and RT (Right side) tell the payer this was a separate procedure on a separate site from the 31267. Dx code 473.0 supports this procedure.

The maxillary sinuses are right behind your cheekbones.

In adults, these are the sinuses where an infection usually occurs. Your maxillary sinuses drain into your nose about one half-inch below the corners of your eyes. This area of your nose is called the osteomeatal  complex.

When this part of your nose is blocked, the maxillary sinuses no longer drain properly and infection can develop. Often, the sinus opening itself becomes blocked, too. The procedure to clear the sinus opening is called a maxillary antrostomy. In an antrostomy, the physician makes an opening (-ostomy) into an antrum -- a cavity or chamber -- so it can drain. The procedure to clear the osteomeatal complex is called an uncinectomy. Usually, both are performed together.

When your ENT performs these procedures endoscopically, you use 31256 or 31267. Though 31267 doesn't specifically refer to polyps, cysts, or other lesions, if the Page 62 Get CPC® certified in 4 days --CodingCert.com 2009, Vol. 11, No. 7/Otolaryngology Coding Alert surgeon removes them -- or any tissue -- from the maxillary sinus, you'll code with 31267.

"To meet the definition of 31267, the maxillary sinuses are opened up and tissue is removed," says Barbara J. Cobuzzi, MBA, CPC,CPC-H, CPC-P, CENTC, CHCC, president of CRN Healthcare Solutions in Tinton Falls, N.J. "That can be polypoid tissue as well as mucoid tissue."

Note: If the surgeon removed diseased mucosa, that's tissue. If your ENT cleans out mucous, that's not tissue and would not qualify for 31267, Cobuzzi adds.

Don't make this error: Do not code the procedure described in this op note 31237 (Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement [separate procedure]). As 31237 is listed as a separate procedure, you would call on it when that is the only procedure that was performed. In this case, the ENT performed an antrostomy as well as a polypectomy.