I'm fairly new to sinus surgery coding for the orthopaedic hospital I work for and need assistance with documentation issues I have noticed on the following OR. We have a few ENT/sinus specialists who use our facilities, so need to beef up on my knowledge and guidance! Any expert advisors out there who could assist would be greatly appreciated.
Specifically, the surgeon states he performed bilateral maxillary antrotomy (antrostomy?) as well as bilateral inferior turbinate out-fracture; however, I do not see any of this documented. The surgeon also states he performed bilateral concha bullosa resection; however, I only see the left side documented.
The codes I have are 31276-LT, 31297-LT, 31254-50, 30520, and 31240-LT. Am I accurate here? I need to try to explain to my surgeon why I would be leaving Modifier 50 off 31240 and not coding 31256-50 or 30930. Help! (Note: The Propel we don't code per internal guidance.)
PREOPERATIVE DIAGNOSES: Chronic sinusitis, deviated septum, and turbinate hypertrophy.
POSTOPERATIVE DIAGNOSES: Chronic sinusitis, deviated septum, and turbinate hypertrophy.
OPERATIVE PROCEDURE: Nasal septal reconstruction, bilateral outfracture of the inferior turbinates, bilateral endoscopic anterior ethmoidectomy with Propel, bilateral endoscopic maxillary antrotomy with bilateral endoscopic concha bullosa resection, and left endoscopic sphenoidotomy with balloon.
ANESTHESIA: General.
INDICATIONS FOR PROCEDURE: The patient is a X-year-old male with a history of chronic recurrent pansinusitis with nasal obstruction refractory to medical management.
OPERATIVE TECHNIQUE: The patient brought into the operating room and laid in the supine position. After adequate induction of general endotracheal anesthesia, the patient prepped and draped in the usual sterile fashion. Nose injected with 4 cc of 1% Xylocaine with epinephrine 1:100,000 dilution and packed with 0.5% Neo-Synephrine soaked cottonoids. All packs removed. A left hemitransfixion incision was made and mucoperichondrium flaps elevated. Posterior bony obstruction excised. Maxillary crest spur was excised. A 1 x 1 cm strip of midportion of quadrangular cartilage was excised. The remainder of the quadrangular cartilage preserved. A quilting stitch of 4-0 chromic placed. Incision closed with 4-0 chromic. It should be noted I took down an anterior septal bony spur off the nasal floor. After all sutures placed, I did go to the left-hand side. I reflected the middle turbinate laterally, identified the superior turbinate, identified the ostium of the sphenoid, passed the guidewire and the balloon, inflated, deflated, and removed. Ultimately inflated to 6 cm. I then did a more standard FESS technique to remove disease and tissue from the floor of the left frontal sinus. Following this, infundibulotomy was carried out under 30 degree Storz endoscopic control. Uncinate process, ethmoid bulla, and middle compartments were taken down. The posterior system left intact. Natural ostium was completely occluded. Therefore, opened to 1.5 cm, brought anterior and inferior, and mucosal disease removed from the ostium. Large concha bullosa air cell resected with the lateral lamina, preserving the medial lamina of the same. Following this, I directed attention to the right side. An infundibulotomy was carried out under 30 degree Storz endoscopic control. Uncinate process, ethmoid bulla, and middle compartments were taken down. The natural ostium was opened to 1.5 cm, brought anterior and inferior, and mucosal disease removed from the ostium. Following this and being happy with the dissection at this point in time, the nose was dressed with mini Propel implants, followed by Surgifoam, followed by Doyle splints and 3-0 Prolene. Neosporin penetrated Telfa packing was applied. Careful inspection of the nasopharynx showed no further cartilage or foreign body. Likewise, oral cavities and oropharynx carefully suctioned and no sign of foreign body. After Doyle splints secured with 3-0 Prolene and Neosporin penetrated Telfa packing being applied, procedure terminated. Estimated blood loss was minimal. Eyes and skull base stable throughout. No signs of intraorbital or intracranial injury. No sign of CSF leak or nasolacrimal duct injury. The patient tolerated the procedure well, leaving the operating room in stable.
Specifically, the surgeon states he performed bilateral maxillary antrotomy (antrostomy?) as well as bilateral inferior turbinate out-fracture; however, I do not see any of this documented. The surgeon also states he performed bilateral concha bullosa resection; however, I only see the left side documented.
The codes I have are 31276-LT, 31297-LT, 31254-50, 30520, and 31240-LT. Am I accurate here? I need to try to explain to my surgeon why I would be leaving Modifier 50 off 31240 and not coding 31256-50 or 30930. Help! (Note: The Propel we don't code per internal guidance.)
PREOPERATIVE DIAGNOSES: Chronic sinusitis, deviated septum, and turbinate hypertrophy.
POSTOPERATIVE DIAGNOSES: Chronic sinusitis, deviated septum, and turbinate hypertrophy.
OPERATIVE PROCEDURE: Nasal septal reconstruction, bilateral outfracture of the inferior turbinates, bilateral endoscopic anterior ethmoidectomy with Propel, bilateral endoscopic maxillary antrotomy with bilateral endoscopic concha bullosa resection, and left endoscopic sphenoidotomy with balloon.
ANESTHESIA: General.
INDICATIONS FOR PROCEDURE: The patient is a X-year-old male with a history of chronic recurrent pansinusitis with nasal obstruction refractory to medical management.
OPERATIVE TECHNIQUE: The patient brought into the operating room and laid in the supine position. After adequate induction of general endotracheal anesthesia, the patient prepped and draped in the usual sterile fashion. Nose injected with 4 cc of 1% Xylocaine with epinephrine 1:100,000 dilution and packed with 0.5% Neo-Synephrine soaked cottonoids. All packs removed. A left hemitransfixion incision was made and mucoperichondrium flaps elevated. Posterior bony obstruction excised. Maxillary crest spur was excised. A 1 x 1 cm strip of midportion of quadrangular cartilage was excised. The remainder of the quadrangular cartilage preserved. A quilting stitch of 4-0 chromic placed. Incision closed with 4-0 chromic. It should be noted I took down an anterior septal bony spur off the nasal floor. After all sutures placed, I did go to the left-hand side. I reflected the middle turbinate laterally, identified the superior turbinate, identified the ostium of the sphenoid, passed the guidewire and the balloon, inflated, deflated, and removed. Ultimately inflated to 6 cm. I then did a more standard FESS technique to remove disease and tissue from the floor of the left frontal sinus. Following this, infundibulotomy was carried out under 30 degree Storz endoscopic control. Uncinate process, ethmoid bulla, and middle compartments were taken down. The posterior system left intact. Natural ostium was completely occluded. Therefore, opened to 1.5 cm, brought anterior and inferior, and mucosal disease removed from the ostium. Large concha bullosa air cell resected with the lateral lamina, preserving the medial lamina of the same. Following this, I directed attention to the right side. An infundibulotomy was carried out under 30 degree Storz endoscopic control. Uncinate process, ethmoid bulla, and middle compartments were taken down. The natural ostium was opened to 1.5 cm, brought anterior and inferior, and mucosal disease removed from the ostium. Following this and being happy with the dissection at this point in time, the nose was dressed with mini Propel implants, followed by Surgifoam, followed by Doyle splints and 3-0 Prolene. Neosporin penetrated Telfa packing was applied. Careful inspection of the nasopharynx showed no further cartilage or foreign body. Likewise, oral cavities and oropharynx carefully suctioned and no sign of foreign body. After Doyle splints secured with 3-0 Prolene and Neosporin penetrated Telfa packing being applied, procedure terminated. Estimated blood loss was minimal. Eyes and skull base stable throughout. No signs of intraorbital or intracranial injury. No sign of CSF leak or nasolacrimal duct injury. The patient tolerated the procedure well, leaving the operating room in stable.