Otolaryngology Coding Alert

Coders may have noticed that the five codes at the end of the Sinus Endoscopy section of CPT 2002 differ from other functional endoscopic sinus surgery (FESS) codes in three ways: 1) the nature and complexity of the procedures they describe, 2) the number of days in the surgical package (10 global days versus 0 global days for most other FESS procedures) and 3) the number of relative value units (RVUs) assigned (26-33 RVUs versus 4-16 RVUs for most FESS procedures).
 
The codes include:

31290 nasal/sinus endoscopy, surgical, with repair of cerebrospinal fluid leak; ethmoid region

31291 sphenoid region

31292 nasal/sinus endoscopy, surgical; with medial or inferior orbital wall decompression

31293 with medial orbital wall and inferior orbital wall decompression

31294 with optic nerve decompression.    
CSF Leak Repair  
Codes 31290-31291 include repairs to cerebrospinal fluid (CSF) leaks that were performed as open procedures before the advent of endoscopic procedures, says Sanford Archer, MD, an otolaryngologist and associate professor at the University of Kentuckys College of Medicine in Lexington, Ky., chairperson of the Patient Safety and Quality Improvement Committee of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) and a member of the academys Rhinology and Paranasal Sinus Committee. Repairing a CSF leak endoscopically lessens the risk to the patient. Previously, when the procedure was performed using craniotomy (pulling back the frontal lobe), damage to the olfactory system often resulted, and there was a greater risk of visual damage to the optic nerves, Archer says.
 
To repair a CSF leak in the ethmoid region, the ethmoid sinus is entered, the leak is isolated, and grafts or flaps may be used to seal the leak. To repair a sphenoid leak, the endoscope may enter the sphenoid directly through the septum or via the ethmoid sinuses.
 
Ethmoidectomy 31254 (nasal/sinus endoscopy, surgical; with ethmoidectomy, partial [anterior]) or 31255 ( with ethmoidectomy, total [anterior and posterior]) may not be billed if it is performed to provide access to the CSF leak repair. If the otolaryngologist discovers a CSF leak while performing an ethmoidectomy or if the patient develops a CSF leak during the surgery, however, ethmoidectomy may be billed along with 31290, says Melissa Pointer, CPC, billing manager with the otolaryngology division at the University of Arkansas Medical Center in Little Rock.
 
Pointer says that modifier -59 (distinct procedural service) should be appended to the appropriate ethmoidectomy code or other FESS code in such cases to let the carrier know that the ethmoidectomy was performed first for a separate reason. The ethmoidectomy should be linked to a separate diagnosis code (for example, 473.2 [chronic ethmoidal sinusitis]); 31290 should also be linked to a related diagnosis code (for example, 349.81 [cerebrospinal fluid rhinorrhea]).
Decompression Procedures  
Codes 31292-31294 [...]