such78
Expert
DX: right chronic sinusitis
Procedure:
1. right ethmoidectomy with frontal sinus exploration
2. right maxillary antrostomy with tissue removal
Using a 0-degree endoscope, bilateral nasal cavity was examined and purulence was noted to emanate from the right maxillary ostia. Approximately 10 cc of lidocaine with epinephrine was injected into the uncinate area on the right. Using a Cottle knife, an uncinectomy incision was made and the uncinate bone was taken down using a straight Blakesley. the maxillary antrostomy was then widened using a backbiting forceps. purulence was noted to emanate from the maxillary sinus and culture swabs were used to take cultures from the maxillary sinus. Additionally, edematous thickened tissue was removed from the maxillary sinus and sent to pathology labeled as maxillary content. After this was completed, as Acclarent balloon sinuplasty catheter was threaded through the frontal recess and the area was dilated x 3. Attention was then turned to the ethmoid sinus where the ethmoid bones were taken down using a straight Frazier tip suction. After this was completed, the procedure was concluded.
I assign 31267 - for removal tissue via maxillary
The highlighted performance qualified for the CPT 31253? I am confused because the surgeon did not indicate the ethmoidectomy was done for partial or total ( anterior + posterior). He only mentioned ethmoid bones were takedown.
Please advice. Thank you.
Procedure:
1. right ethmoidectomy with frontal sinus exploration
2. right maxillary antrostomy with tissue removal
Using a 0-degree endoscope, bilateral nasal cavity was examined and purulence was noted to emanate from the right maxillary ostia. Approximately 10 cc of lidocaine with epinephrine was injected into the uncinate area on the right. Using a Cottle knife, an uncinectomy incision was made and the uncinate bone was taken down using a straight Blakesley. the maxillary antrostomy was then widened using a backbiting forceps. purulence was noted to emanate from the maxillary sinus and culture swabs were used to take cultures from the maxillary sinus. Additionally, edematous thickened tissue was removed from the maxillary sinus and sent to pathology labeled as maxillary content. After this was completed, as Acclarent balloon sinuplasty catheter was threaded through the frontal recess and the area was dilated x 3. Attention was then turned to the ethmoid sinus where the ethmoid bones were taken down using a straight Frazier tip suction. After this was completed, the procedure was concluded.
I assign 31267 - for removal tissue via maxillary
The highlighted performance qualified for the CPT 31253? I am confused because the surgeon did not indicate the ethmoidectomy was done for partial or total ( anterior + posterior). He only mentioned ethmoid bones were takedown.
Please advice. Thank you.