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After informed consent had been obtained, the patient was taken to the
operating room, laid on the table in supine position. After smooth induction
of general endotracheal anesthesia had been accomplished, the patient's vital
signs were monitored throughout and they were noted to be stable. The septum
was infiltrated with a total of 9 mL of 1% lidocaine with 1:100,000
epinephrine solution into the submucoperichondrial layers on the right and on
the left. An additional 3 mL of the same solution was also infiltrated into
the right and left inferior turbinates. Afrin-soaked cottonoids were placed
in an inch intranasally. A throat pack was placed. The Medtronic image
guidance system was then registered and accuracy was noted. The patient was
then prepped and draped in the normal sterile fashion. A time-out was taken
to both identify the patient and the procedure.
The Afrin-soaked cottonoids were removed. Biopsies were taken from the left
and the right nasal polyps. Using the 0-degree nasal endoscope and a 0 degree
4 mm straight microdebrider blade set at 5000 revolutions, I dissected and
then resected polyps from the anterior to posterior direction back to the
level of nasopharynx on the right and the left. It was at this point then
that I first addressed the septum. A 15 blade was used to create a Killian
incision within the left nasal vestibule. Ipsilateral and contralateral
mucoperichondrial leaflets were then elevated back to the bony collagenous
junction. A Takahashi was used to create an anterior notch within the
cartilage. A swivel knife was used to excise the deviated portion of the
cartilage. I then separated the perpendicular plate of the ethmoid from the
cartilage with a Freer elevator. A Jansen-Middleton was used to take down the
bony deformity of the perpendicular plate of the ethmoid. I then created
inferior tunnels. A 4 mm straight osteotome and mallet was used to take down
the bony deformity along the floor of the nose. The patient's septum was now
in a more midline position. I then turned my attention towards the left
maxillary sinus. The left middle turbinate would be medialized with a Freer
elevator. A backbiter was used to take down the inferior aspect of the left
uncinate process. Remainder of the uncinectomy was performed with 0-degree
microdebrider blade. I then was able to identify and locate the natural os
with the image guided olive tip suction. I then circumferentially enlarged
the ostia with the 0-degree and 40 degree microdebrider blade. I then
resected the polyps from the left maxillary sinus with the 40-degree
microdebrider blade. I then switched back over to the 0-degree microdebrider
blade and resected the polyps within the infundibulum. The ethmoid bulla was
then encountered. This would be entered with a straight Blakesley Weil.
Polypoid tissue and frank polyposis was noted throughout. Preoperatively
throughout the course of the case, I would have to pack the sinuses with Afrin-
soaked cottonoids for hemostasis and then remove and then reassess and resume
my surgery. Dissection was then carried out from the anterior to posterior
direction across the basal lamella into the posterior ethmoids. Care was
taken to avoid trauma to the fovea ethmoidalis into the lamina papyracea. I
then was able to use the image-guided frontal sinus balloon and gain access up
into the left frontal sinus and recess. Serial dilation was performed. This
was somewhat stenotic and made the dilation and the frontal sinusotomy more
challenging. Once I had addressed this, I then packed off the left ethmoids
with Afrin-soaked cottonoids. When I reviewed the images on the CT, the
patient's sphenoid sinuses were not as involved and so in my opinion did not
need to be addressed at this time. I then turned my attention towards the
right maxillary and right ethmoid sinuses. The same procedure that was
performed on the left maxillary and ethmoid sinus was then performed on the
right side. Once again, resection of polyps from the left maxillary sinus was
performed with a 40-degree image-guided microdebrider blade. The left frontal
sinus was very stenotic and the patient has somewhat of a hypoplastic-
appearing left frontal sinus on imaging. I attempted to float the image-
guided balloon up into the frontal recess, but it was unsuccessful given the
stenosis. Once again, the patient's right sphenoid sinus was not as
impressive. Once I reviewed the images again during the surgery and so I did
not attempt the right sphenoidotomy. It was at this point then that I turned
my attention towards the inferior turbinates. A 15 blade was then used to
create a small incision over the anterior face and head of the inferior
turbinates. A Cottle elevator was used to elevate the mucosa up off the
concha. Using a 2.0 inferior turbinate, microdebrider blade was set at 2500
revolutions and using an intraturbinal technique, bilateral submucosal
resection of the inferior turbinates, which included partial resection of the
conchal bone was performed. Outfracturing of the inferior turbinates was then
performed. The patient's airway was now more widely patent. I then suctioned
out the nasopharynx free of any blood. A 4-0 chromic was used to
reapproximate the Killian incision using a septal mattress stitch. Novapaks
were then placed between the lateral nasal walls and the lateral aspect of the
middle turbinates on the right and on the left. They would be infiltrated
with saline. Doyle splints were cut down to size and bacitracin was applied
and they were inserted along the floor of the nose on the right and on the
left. They would be sutured anteriorly through the columella with 3-0
Prolene. The patient's throat pack was removed. A mustache dressing was
applied. The patient was awakened, was extubated, and was transported back to
recovery room in a stable condition.
The patient will be discharged home to the care of her mother in stable
condition with a prescription for Norco 5/325, dispense 15 one p.o. q.6 hours
p.r.n. pain with no refills and cefdinir 300 mg, dispense 14 one p.o. b.i.d.
x7 days. The patient will resume her home medications. Discharge
instructions for maintenance of the patient's nose were also provided. The
patient will follow up in my office in 1 week for splint removal.
Question: would you view the work done on the frontal sinus as a dilation only the 31296 or the 31276? My provider is stating that the sinusotomy should also include dilation which makes sense as well, but on this case I am looking at using one of the combination codes the 31253 for the LT side but then on the right side he abandoned both the sphenoid dilation and Frontal dilation which could also be looked at like it was a -otomy. Wondering what other ENT coders do when they use Dilaton terms with Otomy Codes the maxillary sinus is the only definition that I can find that includes drainage in the Lay term so I am a bit perplexed on using dilation or otomy codes.
operating room, laid on the table in supine position. After smooth induction
of general endotracheal anesthesia had been accomplished, the patient's vital
signs were monitored throughout and they were noted to be stable. The septum
was infiltrated with a total of 9 mL of 1% lidocaine with 1:100,000
epinephrine solution into the submucoperichondrial layers on the right and on
the left. An additional 3 mL of the same solution was also infiltrated into
the right and left inferior turbinates. Afrin-soaked cottonoids were placed
in an inch intranasally. A throat pack was placed. The Medtronic image
guidance system was then registered and accuracy was noted. The patient was
then prepped and draped in the normal sterile fashion. A time-out was taken
to both identify the patient and the procedure.
The Afrin-soaked cottonoids were removed. Biopsies were taken from the left
and the right nasal polyps. Using the 0-degree nasal endoscope and a 0 degree
4 mm straight microdebrider blade set at 5000 revolutions, I dissected and
then resected polyps from the anterior to posterior direction back to the
level of nasopharynx on the right and the left. It was at this point then
that I first addressed the septum. A 15 blade was used to create a Killian
incision within the left nasal vestibule. Ipsilateral and contralateral
mucoperichondrial leaflets were then elevated back to the bony collagenous
junction. A Takahashi was used to create an anterior notch within the
cartilage. A swivel knife was used to excise the deviated portion of the
cartilage. I then separated the perpendicular plate of the ethmoid from the
cartilage with a Freer elevator. A Jansen-Middleton was used to take down the
bony deformity of the perpendicular plate of the ethmoid. I then created
inferior tunnels. A 4 mm straight osteotome and mallet was used to take down
the bony deformity along the floor of the nose. The patient's septum was now
in a more midline position. I then turned my attention towards the left
maxillary sinus. The left middle turbinate would be medialized with a Freer
elevator. A backbiter was used to take down the inferior aspect of the left
uncinate process. Remainder of the uncinectomy was performed with 0-degree
microdebrider blade. I then was able to identify and locate the natural os
with the image guided olive tip suction. I then circumferentially enlarged
the ostia with the 0-degree and 40 degree microdebrider blade. I then
resected the polyps from the left maxillary sinus with the 40-degree
microdebrider blade. I then switched back over to the 0-degree microdebrider
blade and resected the polyps within the infundibulum. The ethmoid bulla was
then encountered. This would be entered with a straight Blakesley Weil.
Polypoid tissue and frank polyposis was noted throughout. Preoperatively
throughout the course of the case, I would have to pack the sinuses with Afrin-
soaked cottonoids for hemostasis and then remove and then reassess and resume
my surgery. Dissection was then carried out from the anterior to posterior
direction across the basal lamella into the posterior ethmoids. Care was
taken to avoid trauma to the fovea ethmoidalis into the lamina papyracea. I
then was able to use the image-guided frontal sinus balloon and gain access up
into the left frontal sinus and recess. Serial dilation was performed. This
was somewhat stenotic and made the dilation and the frontal sinusotomy more
challenging. Once I had addressed this, I then packed off the left ethmoids
with Afrin-soaked cottonoids. When I reviewed the images on the CT, the
patient's sphenoid sinuses were not as involved and so in my opinion did not
need to be addressed at this time. I then turned my attention towards the
right maxillary and right ethmoid sinuses. The same procedure that was
performed on the left maxillary and ethmoid sinus was then performed on the
right side. Once again, resection of polyps from the left maxillary sinus was
performed with a 40-degree image-guided microdebrider blade. The left frontal
sinus was very stenotic and the patient has somewhat of a hypoplastic-
appearing left frontal sinus on imaging. I attempted to float the image-
guided balloon up into the frontal recess, but it was unsuccessful given the
stenosis. Once again, the patient's right sphenoid sinus was not as
impressive. Once I reviewed the images again during the surgery and so I did
not attempt the right sphenoidotomy. It was at this point then that I turned
my attention towards the inferior turbinates. A 15 blade was then used to
create a small incision over the anterior face and head of the inferior
turbinates. A Cottle elevator was used to elevate the mucosa up off the
concha. Using a 2.0 inferior turbinate, microdebrider blade was set at 2500
revolutions and using an intraturbinal technique, bilateral submucosal
resection of the inferior turbinates, which included partial resection of the
conchal bone was performed. Outfracturing of the inferior turbinates was then
performed. The patient's airway was now more widely patent. I then suctioned
out the nasopharynx free of any blood. A 4-0 chromic was used to
reapproximate the Killian incision using a septal mattress stitch. Novapaks
were then placed between the lateral nasal walls and the lateral aspect of the
middle turbinates on the right and on the left. They would be infiltrated
with saline. Doyle splints were cut down to size and bacitracin was applied
and they were inserted along the floor of the nose on the right and on the
left. They would be sutured anteriorly through the columella with 3-0
Prolene. The patient's throat pack was removed. A mustache dressing was
applied. The patient was awakened, was extubated, and was transported back to
recovery room in a stable condition.
The patient will be discharged home to the care of her mother in stable
condition with a prescription for Norco 5/325, dispense 15 one p.o. q.6 hours
p.r.n. pain with no refills and cefdinir 300 mg, dispense 14 one p.o. b.i.d.
x7 days. The patient will resume her home medications. Discharge
instructions for maintenance of the patient's nose were also provided. The
patient will follow up in my office in 1 week for splint removal.
Question: would you view the work done on the frontal sinus as a dilation only the 31296 or the 31276? My provider is stating that the sinusotomy should also include dilation which makes sense as well, but on this case I am looking at using one of the combination codes the 31253 for the LT side but then on the right side he abandoned both the sphenoid dilation and Frontal dilation which could also be looked at like it was a -otomy. Wondering what other ENT coders do when they use Dilaton terms with Otomy Codes the maxillary sinus is the only definition that I can find that includes drainage in the Lay term so I am a bit perplexed on using dilation or otomy codes.