Otolaryngology Coding Alert

Question: The provider performs bilateral endoscopic maxillary antrostomies and bilateral endoscopic ethmoidectomies. Additionally, he performs a bilateral inferior turbinate coblation and an excision of the right middle turbinate. I cannot figure out what code to assign for the excision of the middle turbinate.

Michigan Subscriber

Answer: Actually, in the example you provide, you will not code the middle turbinate excision at all. That’s because you should include the middle turbinate excision in the provider’s surgical approach leading up to the right-sided ethmoidectomy and maxillary antrostomies.

This scenario is similar to the hypothetical scenario of a physician performing a bilateral ethmoidectomy in addition to a bilateral frontal sinusotomy. You will code bilateral ethmoidectomies as 31255 (Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior)) with modifier 50 (Bilateral Procedure). The bilateral maxillary antrostomies can be one of two codes depending on what the surgeon performs and documents.

If the provider documents removal of tissue from both left and right maxillary sinuses, you will code the maxillary antrostomies as 31267-50 (Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus). If the documentation does not show any removal of tissue from inside the maxillary sinuses, you will code 31256-50 (Nasal/sinus endoscopy, surgical, with maxillary antrostomy). If the documentation shows that the provider removes tissue from one of the maxillary sinuses but not the other side, you will code the maxillary sinuses as 31267, 31256-59.

By the same token, it’s important to know that payers view a middle turbinate resection as an access route to the ethmoid and maxillary sinuses — which is why the National Correct Coding Initiative (NCCI) chooses to bundle the turbinate resection into the ethmoidectomy and maxillary antrostomy. This might not be as obvious since the code descriptions for turbinate services were changed in 2006 to specify “inferior turbinates” only. If the provider performs a middle turbinate resection on its own or with other, nonbundled services, you will have to report the service using code 30999 (Unlisted procedure, nose).

Based on the information you provide in this example, you may report the following services:

• 31255-50
• 31256-50 (Nasal/sinus endoscopy, surgical, with maxillary antrostomy).

Coder’s note: Just because you must include a middle turbinate excision in the approach for an ethmoidectomy and/or maxillary antrostomy, you shouldn’t make the same assumption about an inferior turbinate coblation. This procedure, as the NCCI edits prove, is separate from endoscopic sinus surgeries. There is usually no need for the provider to perform an inferior turbinate destruction procedure in order to access one or more of the sinuses.