Take a Deep Breath

The respiratory system is complex and can be confusing for coders based on the documentation of procedures utilized to either assist in diagnostic evaluation or therapeutic treatment. The first step in correct coding of procedures for respiratory system is a firm grasp of the anatomic subsections of this complex system. So let’s start at the top the parts of the system which include the nose, pharynx, larynx, trachea, bronchi, and lungs.

The structure of the respiratory system is broken down into two parts, the upper and the lower respiratory system. The upper respiratory system includes the nose, and pharynx. The location of the sinus cavities are one of the biggest issues in understanding CPT code assignment for endoscopic sinus surgeries. Below we can see the positioning of each sinus cavity. The maxillary sinus (maxillary antrum), is below the eye, the ethmoid sinus is between the eye and the nose or nasal cavity, the sphenoid sinus is behind the nasal cavity and the frontal sinus is above the eye, in the forehead region. Surgery on any of the sinuses takes place different locations. Surgery is performed through an incision in either the face or forehead. These open surgeries are coded in the 31000-31230 series of CPT codes.

But our topic is endoscopic nasal procedures so let’s take a look at some of those procedure in depth. These procedures are performed by means of a fiberoptic telescope or an endoscope. Endoscopic sinus surgery is most commonly performed for infected, obstructed or swollen sinus tissues. Common diseases and disorders for endoscopic sinus surgery are as follows:

  • Chronic sinusitis unresponsive to medical treatment
  • Recurrent sinusitis
  • Nasal polyposis
  • Antrochoanal polyps (benign growth, usually arises from the maxillary antrum.
  • Sinus mucoceles (Mucoceles are cystic lesions caused by obstruction of as mucus secreting gland.)
  • Excision of selected tumors
  • Cerebrospinal fluid (CSF) leak closure
  • Orbital decompression (e.g., Graves ophthalmopathy)
  • Optic nerve decompression
  • Dacryocystorhinostomy (DCR)( Restoration of flow of tears into the nose from the lacrimal sac
  • Choanal atresia repair (blockage of the nasal passages (choana) leading from the back of the nose to the throat resulting in mouth breathing)
  • Foreign body removal
  • Epistaxis control

Diagnostic nasal endoscopic procedures 31231 – 31235

The fiberoptic telescope is flexible and smaller in diameter, which allows increased access to multiple areas in the nasal cavity. This type of scope is often used in otolaryngologies offices for diagnostic and simple procedures.
The rigid endoscope affords superior image clarity, facilitates culture and tissue sampling, controls epistaxis better, and affords the endoscopist the ability to perform surgery.
Diagnostic endoscopic procedures are used for the inspection of the nasal cavity; each CPT code in the diagnostic nasal endoscopic family includes inspection of all of these areas:

  • Interior nasal cavity
  • Middle and superior meatus
  • Turbinates
  • Spheno-ethmoid recess

So it is very important to understand all of the areas the physician decided to include in any diagnostic endoscopic procedure. If the physician views the nasal cavity and does a maxillary sinusoscopy; we see that part of the code describes the approach, 31233 (via inferior meatus or canine fossa puncture). If we are coding a diagnostic nasal endoscopy that enters either the maxillary or the sphenoid sinuses then we choose the codes that include these structures as well as the areas listed in 31231. Remember, the codes in this family are unilateral except for 31231, so if you are coding a bilateral procedure, you must use modifier – 50.

Endoscopic Surgery 31237 -312947
When you are coding nasal/sinus endoscopic surgical procedures, any diagnostic endoscopic procedures done in tandem with a surgical procedure should not be coded separately. Also included in all of these procedures are sinusotomies, which are endoscopic incisions, made in a sinus to prevent or reduce inflammation. When coding a nasal/sinus endoscopic procedure; surgical with a biopsy, polypectomy or debridement you will notice that there is a parenthetical “separate procedure” note after this code. These notes are often overlooked by coders and are really important for correct code selection. CPT states that a separate procedure identifies services that are commonly carried out as a fundamental part of a total service (another type of surgery) and as such do not usually warrant separate identification. Meaning that 31237 describes services that are often included in other, more complex surgeries, and commonly 31237 should only be used if the services described in the code, biopsy, polypectomy or debridement are done alone. The additional codes in this family are continuations of 31237, which add other services such as (31238) control of nasal hemorrhage or (31240) with concha bullosa resection to the basic code description. Pay special attention to the excludes notes for this code family, because they give instructions how to code other complex endoscopic nasal surgeries that include services listed in this code family that are intragral to other more complex procedures. This code family is also unilateral and will require modifier -50 is a bilateral procedure is performed.

Nasal Endoscopy with Ethmoid removal 31254 – 31255

Codes 31254 – 31255 cover nasal endoscopic procedures with ethmoidal removal. The ethmoid sinuses are not single sacs. They are a assortment of six to 12 small air cells that open independently into the nasal cavity. They are divided into front, middle, and rear groups. The ethmoid sinuses are located between the eyes and the bridge of the nose. They’re strategic to treating most chronic sinus infections because all of the other sinuses drain through or next to them. An ethmoidectomy removes infected tissue and bone in the ethmoid sinuses that blocks natural drainage.
As with the codes prior that we discussed any diagnostic nasal/sinus endoscopic procedure any sinusotomies are included in these codes when done during the same operative encounter. A sinusotomy is a surgical operation in which an incision is made in a sinus to prevent or reduce inflammation. This code family is presented as a unilateral code and if a bilateral endoscopic procedure is done a modifier of -50 must be added. Pay special attention to the exclude notes as they contain coding advice for more complex procedures complete with an ethmoidectomy and the addition of other procedures outside the ethmoid sinus.
Many of the endoscopic nasal surgeries listed in the CPT book include a surgical procedure called resection of the osteo meatal complex. The OMC is a space beneath the middle turbinate, including the outflow tract for mucus and air from the maxillary sinus. Mucus and air moves through the osteo meatal complex and is a frequent cause of infection in the maxillary, ethmoid and frontal sinuses. The resection of the OMC is a common solution for chronic sinusitis. An antrostomy is an opening made into the maxillary sinus beneath the inferior turbinate. Accessory polyps and degenerate mucosa are removed with a snare, septum forceps, and suction.
So if you are coding an endoscopic exploration of the frontal sinus, with a resection of the OMC and an antrostomy, and a partial ethmoidectomy with poly removal the reported codes should be (31254 for ethmoidectomy and polyp removal, 31256 for the maxillary antrostomy, and 31276 for the frontal sinus exam.

Once it is the anatomy of the nasal cavity is understood, CPT coding for endoscopic procedures is much easier. As we have seen in our examples coding these procedures is based on each area entered and from the nasal cavity, turbinates to complexities of the sinuses and the compartments surrounding them. Each step in an endoscopic procedure that goes into another area is added to insure a complete description of the procedures performed for each encounter. The key is the anatomy and a complete understanding of each type of exam, resection, or removal. Using these key components for each type of nasal surgery will allow to code any endoscopic procedure that comes you way.

Sandra L. Draper is the Director of Training and Development for Precyse Solutions and is experienced health information professional with over 20 years of HIM management and coding experience.

Which anatomical part listed below is included in a complete endoscopic sinus exam?
The maxillary sinus
The turbinates
The Osteo meatal complex
The antral mucosa

All of the nasal endoscopic procedures are unilateral?

When coding a nasal endoscopic partial removal what procedure listed below is considered intragral to the procedure and not coded?
An antrostomy
Diagnostic nasal/sinus endoscopy
Polyp removal
Frontal sinus exploration

A bilateral exam of the nasal cavities, turbinates and sphenoidal recesses is done what is the correct code assignment?

B, B, B, C

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