January 2010

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Coding Challenges for Discussion

Nasal Sinus Endoscopy Case Study

Ambulatory Surgery Setting

Preoperative diagnosis: Nasal septal deviation, hypertrophic inferior turbinates, nasal airway obstruction, chronic frontal ethmoid, and maxillary sinusitis with sinus polyposis.

Postoperative diagnosis: Same

Procedure:  Nasal/sinus endoscopy, surgical, with frontal sinus exploration, right.
Nasal/sinus endoscopy, surgical, with frontal sinus exploration, left.
Nasal/sinus endoscopy, surgical, with anterior and posterior ethmoidectomy, right.
Nasal/sinus endoscopy, surgical, with anterior and posterior ethmoidectomy, left.
Septoplasty.
Nasal/sinus endoscopy, surgical, with maxillary antrotomy and polypectomy, right.
Nasal/sinus endoscopy, surgical, with maxillary antrotomy and polypectomy, left.
Submucous resection of inferior turbinate, right.
Submucous resection of inferior turbinate, left.

History: The patient is a 17-year-old, Caucasian male presenting with a history of chronic nasal obstruction and chronic sinusitis. He has been refractory to conservative therapy. Pre-op evaluation reveals an obvious gross nasal septal deformity, with hypertrophic inferior turbinates, causing bilateral nasal airway obstruction. His pre-op CT scan confirms these findings, along with evidence of polypoid degeneration involving the maxillary, ethmoid, and frontal sinuses. The recommendations for septoplasty with endoscopic sinus surgery were given to the patient and his mother. All benefits, risks, alternate therapies, expected outcomes were discussed. Consent form signed. The patient presents at this time for this procedure.

Details of Procedure: The patient was taken to the operating suite and placed in the supine position. General anesthesia with endotracheal intubation was carried out by the department of anesthesia. Following adequate anesthesia, the table was turned.

Further preparation of the nasal cavity was carried out in the usual manner. Following this, the patient was properly draped and the procedure begun.

A #15 blade was used to make a Killian incision into the left aspect of the mucoperichondrium. A mucoperichondrial and mucoperiosteal flap was then developed. The cartilaginous septum was detached from the maxillary crest and from the bony septum, and a portion of reflected bony septum causing obstruction was taken down with a Gorney scissors and a biting Takahashi forceps. The large bony spur coming out the maxillary crest was then taken down with a curved chisel and mallet technique. Bone fragments were removed with a biting forceps. Following this, the cartilaginous septum was allowed to swing to the midline and attention was turned to the endoscopic portion of the procedure.

The zero-degree endoscope was inserted into the left nasal cavity and brought up to the head of the left middle turbinate. The left middle turbinate was medialized. An infundibulotomy incision was made, followed by uncinectomy. The maxillary antrum was then entered. The antrotomy opening was widened with the Xomed straight shot microdébrider. Polypoid tissue encountered in the left maxillary sinus was then visualized and evacuated with a series of biting forceps. Following this, the débrider was used to gain access to the anterior, then the posterior, ethmoid air cells, removing diseased mucoperiosteal tissue along the way. The nasal frontal recess was then identified. Polypoid tissue in this region was evacuated. The nasof rental duct was then cannulated. Further disease around the duct was removed with the débrider. Following these maneuvers, submucous resection of the left inferior turbinate was then carried out. Next, attention was turned to the opposite maxillary, ethmoid and frontal sinuses. Identical procedures and findings were noted here. Submucous resection of the right inferior turbinate was then carried out.

The middle turbinates were then sutured in the midline, utilizing 4-0 VICRYL on a PS2 cutting needle. Silastic splints, Merocel sinus and nasal packs were then placed. The oral cavity was then suctioned of all blood and debris. The patient tolerated these procedures well. He was turned back over to the department of anesthesia, and was taken to the recovery room in satisfactory condition.

Select the correct procedure codes for this patient.

  1. 31276-50, 31255-50, 30140-50-59, 30520, 31256-50
  2. 31276, 31255, 30140, 30520, 31256
  3. 31276-50, 31255-50, 30520, 31256-50

Feedback:

  1. Correct answer!
  2. Incorrect answer. CPT codes for sinus endoscopy require modifiers to identify whether the procedure was performed on the left side (LT), right side (RT), or bilaterally (50). See AMA CPT Assistant (April 2003): 25.
  3. Incorrect answer. According to CPT coding guidelines, it is inappropriate to report CPT code 30140 in addition to CPT code 31255 since the middle turbinate is part of the ethmoid bone and the approach to access procedures performed in the sphenoid, maxillary, or frontal sinus procedures. Therefore, in this case, the inferior turbinate resection is coded with modifier -59 to show that it is a distinct procedure. In addition, the source document identified the patient’s sinusitis as chronic, not acute. See AMA CPT Assistant (May 2003): 5-6.

Reference

Clinical Coding Workout, 2010 edition. Chicago, IL: AHIMA, 2010.

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