Follow Example Operative Note to Help Code Common ENT Procedure Correctly

The reimbursement rates for many ASC procedures have benefited and will benefit under the new Medicare payment system. One such procedure seeing a noticeable reimbursement boost is endoscopy with ethmoidectomy (surgical drainage of the ethmoid sinus). Total endoscopy with ethmoidectomy (CPT code 31255) will see its reimbursement increase 31 percent at the 2008 fully implemented rate. If your ASC performs ENT procedures, this is a case that you may see more often because of this reimbursement boost.

To help you code such cases correctly, Susan E. Garrison, CHC, PCS, FCS, CCS-P, CPAR, CPC, CPC-H, the executive vice president of healthcare consulting services for Magnus Confidential, shares an example operative note for this procedure, then analyzed it to guide you through how you should properly code the case.

Note: We have italicized the information you would have wanted to highlight to ensure proper coding.

Sample operative note
Preoperative diagnosis:
1.    Chronic hyperplastic rhinosinusitis
2.    Allergies
3.    Asthma
4.    Status post prior polypectomy and sinus surgery

Postoperative diagnosis: Same.

Operative procedure:

Left sinusotomy (three or more sinuses) to include:
•    Nasal and sinus endoscopy
•    Endoscopic intranasal polypectomy
•    Endoscopic total ethmoidectomy
•    Endoscopic sphenoidotomy
•    Endoscopic nasal antral windows, middle
meatus, and inferior meatus
•    Endoscopic removal of left maxillary sinus
contents

Right sinusotomy (three or more sinuses) to include:
•    Nasal and sinus endoscopy
•    Endoscopic intranasal polypectomy
•    Endoscopic total ethmoidectomy
•    Endoscopic sphenoidotomy
•    Endoscopic nasal antral windows, middle meatus, and inferior meatus
•    Endoscopic removal of right maxillary sinus contents

Anesthesia: General endotracheal.

Estimated Blood Loss: 250 cc.

Fluids Replaced: 1200 cc.

Specimens sent to pathology:
1.    Left ethmoid and spheroid contents for routine and fungal cultures
2.    Right maxillary contents for routine and fungal cultures
3.    Left intranasal ethmoid, spheroid, and maxillary specimens for pathology
4.    Right ethmoid, spheroid, maxillary, and right intranasal contents for
pathology

Complications: None.

Drains/packs: Bilateral Gelfilm in the middle meati. Bilateral Telfa gauze impregnated with Bacitracin. Bilateral Vaseline gauze between the folds of Telfa.

Findings: Complete nasal obstruction by polyps with obscuring of all of the normal landmarks. The right middle turbinate was found and preserved. The residual bode of the left middle turbinate was found and preserved. There was thickened hyperplastic mucosa throughout the sinuses with some polyps in the sinuses and the majority of the sinus cavities were filled with inspissated glue-like mucopurulent debris. At the end of the case there were no visible polyps, the airway was clear and the debris had been removed.

Procedure: The patient was taken to the operating room, placed in the supine position, and general endotracheal anesthesia adequately obtained. A pharyngeal pack was placed. The nose was infiltrated with xylocaine with epinephrine and cottonoids soaked in 4% cocaine were placed. The procedure was performed in a similar manner on the left and right sides. The cottonoids were removed.

The 30-degree wide-angle sinus telescope with endoscrub and the Stryker Hummer device were used to remove the polyps starting anteriorly and working posteriorly. This led to visualization of the middle turbinates.

The middle meati disease was removed. The area of the uncinate process and infundibulum was shaved away and forceps were used to remove portions of bone
particle. Using blunt dissection, the agger nasi cells, ethmoid and spheroid sinuses were entered and the contents removed with forceps and suction. The inferior turbinates were infractured, a mosquito clamp placed through the lateral nasal wall into the maxillary sinuses through the inferior meatus. That opening was opened with forward and backward biting forceps, sinus endoscopy was performed, and inspissated mucus and debris cleaned out of the sinuses.

In a similar manner the sinuses were opened from the middle meatus and the sinuses cleaned. In the above manner, the ethmoid, spheroid, and maxillary sinuses were cleaned of debris and inspissated mucus suctioned from the frontal recesses.

The patient was then suctioned free of secretions, adequate hemostasis noted. Gelfilm was soaked, rolled, and placed in the middle meati). Telfa gauze was impregnated with Bacitracin, folded and placed in the nose. Vaseline gauze was placed between the folds of Telfa. The pharyngeal pack was removed. He was
suctioned free of secretions, adequate hemostasis noted, and the procedure terminated. He tolerated it well and left the operating room in satisfactory condition.

Coding analysis
Since the procedure was bilateral, modifier -50 would apply except to the diagnostic functional endoscopic sinus surgery (FESS). You would not append modifier -50 to the diagnostic FESS because it is inherently bilateral. The diagnostic FESS was performed, which is coded with CPT 31231; however, since additional surgical FESS procedures were performed, you cannot code 31231, says Ms. Garrison. Diagnostic scoped procedures are always bundled into therapeutic scoped procedures when performed during a single session, no exceptions.

Next comes the endoscopic removal of polyps, which would indicate CPT 31237, but since polyp removal was for visualization, you cannot code 31237 either.

Uncinate process and infundibulum were removed in prepping for the ethmoidectomy, so there is no code here (see Jan. 1999 CPT Assistant for guidance), says Ms. Garrison.
This leaves us with the FESS with total ethmoidectomy (CPT 31255 with -50 modifier); maxillary antrostomy with removal of tissue (CPT 31267 with -50 modifier); and sphenoid sinusoscopy with removal of tissue (CPT 31288 with -50 modifier).

Therefore, the codes for this case are 31255-50, 31267-50 and 31288-50.

Note: Under the current Medicare ASC payment system, CPT 31255 has a 2008 payment of $772.90; it has a fully implemented payment, at 2008 projected rates, of $940.59.

CPT 31267 and CPT 31288 have 2008 payments of $617.65; they have fully implemented payments, at 2008 projected rates, of $940.59.

Contact Rob Kurtz at rob@beckersasc.com.