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Don’t forget to pay attention to combo codes and descriptors.

Coding for functional endoscopic sinus surgery (FESS) presents several challenges, as correct code assignment is based not only on your ability to understand nasal anatomy, but also your understanding of what the provider actually performed during the surgery. Here’s a rundown of the different codes that can come into play when your provider performs surgery to restore ventilation and normal functions to a patient’s sinuses.

Begin by Understanding Sinus Anatomy

The sinuses are divided into four regions: ethmoid, sphenoid, maxillary, and frontal. In addition, FESS surgery can also include reducing the size of the turbinates — small structures in the nasal cavity that are responsible for filtering, warming, and humidifying air coming in through the nostrils.

Engage This Ethmoidectomy Knowledge

Most FESS codes describe a procedure on the ethmoid sinuses known as an ethmoidectomy. In this procedure, the provider removes the tissue and bone that separate the air-filled cavities in the ethmoid sinuses. This creates larger spaces within those sinuses, allowing them to drain and function effectively.

If the ethmoidectomy is the only procedure the provider performs, then you will use one of two codes, depending on which ethmoid region the surgeon operated on. If it was the anterior region, you’ll use 31254 (Nasal/sinus endoscopy, surgical with ethmoidectomy; partial (anterior), but if it was both the anterior and posterior regions, also known as a total nasal/sinus ethmoidectomy, you’ll use 31255 (... total (anterior and posterior)).

Remember: Rarely, if ever, will you see a provider document that they only treated the posterior ethmoid sinus, according to Dottie Davis, CPC, COC, CGSG, CEMC, CPMA, physician team lead coder for medKoder in Mandeville, Louisiana.

Consider These Combo Codes When Appropriate

Often, the provider will perform another procedure along with the ethmoidectomy, which gives rise to several combination codes. These include:

• 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)

The tricky part of code assignment with these combo codes is the phrase “removal of tissue.” In order to employ either 31253 or 31259, your provider must document removing things like polyps, fungus balls, or mucus seals, and not simple debris or pus. Additionally, the documentation must note that the tissue removed is from within the sinus, Davis offers as a reminder.

Max Out Your Maxillary Antrostomy and Sphenoidotomy Codes

The same tissue removal distinction will guide your maxillary antrostomy and sphenoidotomy code choice. For maxillary antrostomy procedures, the surgeon creates larger openings in the maxillary sinuses to allow for better drainage. To code the surgery, you’ll use one of the following:

• 31256 (Nasal/sinus endoscopy, surgical, with maxillary antrostomy)
• 31267 (Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus)

Similarly, in sphenoidotomies, the surgeon opens the sphenoid sinus; also, similar to 31253, 31259, and 31267, you have a code for the procedure itself along with a code for the procedure and tissue removal:

• 31287 (Nasal/sinus endoscopy, surgical, with sphenoidotomy)
• 31288 (Nasal/sinus endoscopy, surgical, with sphenoidotomy; with removal of tissue from the sphenoid sinus)

And Be Up Front With Frontal Sinus Exploration

To code this procedure, you only have one code option — 31276 (Nasal/sinus endoscopy, surgical, with frontal sinus exploration, including removal of tissue from frontal sinus, when performed) — whether or not the surgeon chooses to remove tissue, as the descriptor words “when performed” tell you.

Turbo Charge Your Turbinate Excision Coding

Turbinate excisions can also create a headache, even though there is only one code to use: 30130 (Excision inferior turbinate, partial or complete, any method). As its descriptor states, the code is only for excisions of the inferior turbinate, and there is no code for excisions of the superior or middle turbinates. For such procedures, you’ll have to use an unlisted procedure code: 30999 (Unlisted procedure, nose) per the note accompanying 30130. As an unlisted code, 30999 has no relative value units (RVUs) and, therefore, no fee attached to it. So, “if you need a comparable code for pricing, use the code for the inferior turbinate” according to Davis.

And Pay Attention to These 3 Nuances

Nuance 1: The language in several of the CPT^® ethmoidectomy descriptors can be confusing. On the surface, 31276 (Nasal/sinus endoscopy, surgical, with frontal sinus exploration ...) and 31287 (Nasal/sinus endoscopy, surgical, with sphenoidotomy) look very similar to combo codes 31253 (... ethmoidectomy; total (anterior and posterior), including frontal sinus exploration) and 31257 (... ethmoidectomy; total (anterior and posterior), including sphenoidotomy).

However, CPT^® Assistant clarifies that you should report 31253 and 31257 “when a complete/total ethmoidectomy is performed” in addition to the other procedure. For partial ethmoidectomies, you’ll use 31254 along with 31276 for a frontal sinus exploration or 31524 with 31287 for a sphenoidotomy (CPT^® Assistant Volume 28: Issue 4, April 2018).

Nuance 2: Most FESS procedures involve stereotactic navigation, which you will code with +61782 (Stereotactic computer-assisted (navigational) procedure; cranial, extradural (List separately in addition to code for primary procedure)). As the descriptor says, you can code this service separately from the main procedure.

Nuance 3: All the FESS codes describe unilateral procedures, which means you will have to append a laterality modifier such as RT (Right side), LT (Left side), or 50 (Bilateral procedure) to the procedure code per payer preference and as appropriate.

Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC