Otolaryngology Coding Alert

Here’s everything you need to know about Draf sinus procedures.

If a patient suffers from chronic sinusitis/rhinosinusitis or from complications resulting from these diseases, the physician might decide to perform a “Draf” drainage procedure. Candidates for the Draf often resort to this procedure following unsuccessful attempts at more traditional endoscopic approaches.

Draf procedures fall under three specific subsections:

Draf I, Simple Drainage: This includes a partial or total ethmoidectomy along with the removal of any additional obstructing structures, resulting in the creation of a drainage tract from the frontal sinus ostium.

Draf IIa, Extended Drainage: This is essentially an extension of the Draf I procedure, which involves a resection of the frontal sinus floor from the middle turbinate to the lamina papyracea.

Draf IIb, Extended Drainage: When the opening created in IIa is insufficient for drainage, the physician will opt to resect the frontal sinus floor from the nasal septum to the lamina papyracea. Additionally, the physician performs a dissection on the anterior face of the frontal recess as a means of enlarging the frontal sinus ostium for enhanced patency.

Draf III, Median Frontal Drainage (Modified Lothrop Procedure): This procedure includes type IIb bilateral drainage in addition to the removal of the superior portion of the nasal septum, the inferior portion of the frontal sinus septum, and the frontal sinus floor bilaterally.

Food for thought: While the term “Draf” might not be commonplace in some practices, it’s important to keep in mind that procedures emulating Draf drainages (using slightly different terminology) are not unusual.

Jennifer Connell outlines her experience coding a broad range of similarly-worded procedures. “I have never seen my physicians document those procedures specifically. They always document code 31276 as ‘endoscopic frontal sinus surgery,’ which could represent a number of procedures.

“Regardless, ENT coders should understand what the different Draf procedures are and when they can code it as 31276 for endoscopic frontal sinus surgery,” Connell explains. To help you better understand Draf procedures, Connell recommends a quick review of sinus anatomy.  

Draf Procedures Are Complex, But The Coding Isn’t

Believe it or not, each one of these procedures rely on the same frontal sinus endoscopy code: 31276 (Nasal/sinus endoscopy, surgical with frontal sinus exploration, with or without removal of tissue from frontal sinus).

Check first: While these procedures “generally” involve a total ethmoidectomy, you’ll want to confirm in the op notes that no documentation exists of a previous ethmoidectomy on the patient. Assuming that’s not the case (and it’s sufficiently documented in the op notes), you’ll also want to include code 31255 (Nasal/sinus endoscopy, surgical; with ethmoidectomy, total [anterior and posterior]). However, if only an anterior ethmoidectomy is performed, do NOT include code 31254 in addition to 31276. By definition, an anterior ethmoidectomy is included in the approach when performing a frontal sinus exploration.

Keep in mind that if there is no specific documentation for a Draf procedure, you’ll want to take a few measures to make sure that the documentation warrants the use of code 31276. According to Connell, “It is important to remember that CPT^® code 31276 includes a frontal sinusotomy, which requires entry into the frontal sinus. Entering or removing tissue from the frontal sinus recess or ostium only is included in a total ethmoidectomy and should be billed using CPT® 31255.”