Otolaryngology Coding Alert

Use this FAQ to Keep ethmoidectomy types separate.

When your otolaryngologist performs an ethmoidectomy, you’ll have several coding options to sift through.

You’ll need to know the extent of the procedure, as well as the instrumentation the otolaryngologist uses, in order to file the cleanest claims possible.

Check out this FAQ on the ethmoidectomy coding questions you’ll need answers to.

Q: For coding purposes, what is an ethmoidectomy?

A: “An ethmoidectomy is a procedure to remove any infected tissue, bone, or polyps in the ethmoid sinuses,” explains Lisa Jones, CPC, consultant at 360 Practice Management Solutions in Hollywood, Fla.

Since ethmoid sinuses are divided into anterior and posterior regions, CPT^® has two separate codes for reporting surgical ethmoidectomies: 31254 (Nasal/sinus endoscopy, surgical; with ethmoidectomy, partial [anterior]) and 31255 (… with ethmoidectomy, total [anterior and posterior]).

Q: When do you report 31254 vs. 31255?

During a partial (anterior) ethmoidectomy (31254), “the physician uses an endoscope to enter the anterior portion of the nasal cavity,” says Candice Fenildo, CHC, CPC, CPMA, CPC-I, CPB, CENTC, CRHC, and AAPC Fellow, of Acevedo Consulting Inc. in Delray Beach, Fla. Once the endoscope is in place, the otolaryngologist identifies the ethmoid bulla, opens it, and resects it with cutting forceps, continues Fenildo, who is also the chair of the AAPC Chapter Association Board of Directors for 2016-2017.

As part of a 31254 service, the otolaryngologist will likely remove the anterior cells as well. The otolaryngologist may also look up into the frontal sinuses while in the anterior ethmoid sinuses in order to determine the condition of the frontal sinuses, and determine if further surgery is needed in that area.

During a total (anterior and posterior) ethmoidectomy (31255), the otolaryngologist opens the ethmoid sinuses and removes the diseased and loose bony partition from the lamella papyracea in addition to the ethmoid bulla found in the anterior ethmoid sinuses, Fenildo says.

Q: Can the physician perform an ethmoidectomy without endoscope?

A: Yes, though it is rare. The physician might also use an open intranasal approach during the procedure, which will change your coding choices. If the physician doesn’t use an endoscope during anterior surgery, and instead opts for an open intranasal approach, code 31200 (Ethmoidectomy; intranasal, anterior), confirms Jones. If the posterior and anterior cells require surgery and the physician uses an open intranasal approach, code 31201 (… intranasal, total).

More info: During 31200 service, “the physician makes an intranasal incision to gain access into the anterior ethmoid sinus. The provider then removes all diseased contents from the anterior ethmoid sinus,” explains Fenildo. “In 31201, the provider uses an intranasal approach to access the anterior and posterior ethmoid sinuses and removes the diseased contents,” she continues.

Best bet: Check ethmoidectomy encounter notes to ensure endoscope use. If you see no evidence of an endoscope, it’ll likely narrow your code choices to 31200 or 31201. Since the development of functional endoscopic sinus surgery, however, physicians rarely perform open intranasal sinus surgeries. Physicians only use these procedures if there is a condition that they cannot treat via the endoscope.

Q: What constitutes a total extranasal ethmoidectomy?

A: In the rare event that your otolaryngologist performs a total extranasal ethmoidectomy, you’ll choose 31205 (Ethmoidectomy; extranasal, total) for the procedure.

“During a total extranasal ethmoidectomy, the physician accesses the ethmoid sinus through external approach requiring an incision made between the nasal dorsum and medial canthus of the eye and carried down to the medial orbital bone to expose the sinus cavity,” explains Jones. The physician then removes any diseased tissue, adds packing, and closes the incision.

As previously stated, however, these ethmoidectomies aren’t often performed by otolaryngologists.

“Due to improved technology, external ethmoidectomy is infrequent, and has been replaced by endoscopic ethmoid sinus surgery,” according to Jones.

An otolaryngologist may perform an extranasal ethmoidectomy when special circumstances exist, says Jones. Some of these special circumstances include patients with:

• massive facial trauma,
• acute orbital infections,
• acute bacterial sinusitis, or
• severe arterial nose bleeds.

As rare as an open intranasal ethmoidectomy is, you will find that an open extranasal ethmoidectomy is even rarer. If you think you have a 31205 claim on your hands, be sure to check with the provider before filing the claim.

Q: What could an ethmoidectomy op note look like?

A: Check out this sample op note from Fenildo; you might see similar language in your otolaryngologist’s ethmoidectomy op notes:

CC: Sinus drainage, sinus pain
CT scan revealed chronic ethmoidal sinusitis

History:

Medical management has been unsuccessful, therefore we are going to perform an intranasal ethmoidectomy.

Procedure:

The patient is appropriately prepped and anesthetized. I made an intranasal incision to gain access to the middle turbinate. I then partially resected the middle turbinate to remove obstruction. I then inserted a curette to break into the anterior cells of the ethmoid sinus. I removed the diseased contents of the anterior ethmoid sinus drainage commenced. I then packed the nasal area with gauze.No complications.

Coding: For this encounter, you’d report 31200 with J32.2 (Chronic ethmoidal sinusitis) appended to represent the patient’s sinusitis.