SYLVIA Posted Wed 17th of July, 2019 16:10:39 PM
Indication for procedure:
Patient with a left pterygopalatine fossa mass with multiple brain lesions suspicious for metastasis. Has been symptomatic with headaches and left facial swelling. Imaging revealed a left pterygopalatine fossa mass involving the posterior aspect of the maxillary sinus. A prior CT guided biopsy was attempted, which was non-diagnostic. Given need for diagnosis, biopsy via maxillary antrostomy versus caldwell-luc approach was recommended.
The brainLAB navigation system was brought into the field and the patient was appropriately registered on the system. The appropriate instruments were registered and accuracy was confirmed. Oxymetazoline pledgets were placed into the left nasal cavity for decongestion and hemostasis. The pledgets were removed and 1% lidocaine with 1:100000 epinephrine was injected into the axilla of the middle turbinate. A freer elevator was used to medialize the middle turbinate and expose the uncinate process. A Cottle was used to incise the uncinate process and free it from the lateral nasal wall. A Takahashi forceps was used to grasp the freed uncinate process, exposing the middle meatus and allowing visualization of the left maxillary sinus ostium. A straight through cut forceps was then used to widen the ostium posteriorly to the posterior maxillary sinus wall and widen in anteriorly to the roof of the maxillary sinus. The posterior maxillary wall was taken down to reveal the PPF. A Kerrison was used to remove the thinned bone and improve the exposure of the soft tissue posterior to the wall. Once adequate exposure was obtained, there was noted to be a soft tissue mass in the retromaxillary space. A Blakesley forceps was used to biopsy the tissue and this specimen was sent for frozen pathology. An additional biopsy was taken for permanent pathology. Some bleeding was noted to be coming from the sphenopalatine artery. The artery was identified and a clip was applied endoscopically. Hemostasis was further achieved with the use of Floseal, A Valsalva maneuver was performed and hemostasis was confirmed. An orogastric tube was passed and the stomach contents were suctioned. This concluded the operative portion of the procedure. Physician want to code 61605. I'm thinking since this was an endoscopic biopsy of pterygopalatine mass CPT code unlisted code 30999 or 31299 & 61782 and include the maxillary antrostomy. Is this correct? or what are your recommendations?
SuperCoder Answered Thu 18th of July, 2019 02:45:14 AM
Thanks for your question.
The pterygopalatine fossa (PPF) is a difficult-to-access anatomic area. It is located behind the posterior wall of the maxillary sinus, bordered by the pterygoid plates posteriorly and the greater sphenoid wing and middle cranial fossa superiorly. Standard approaches to the PPF require transmaxillary techniques.
If physician has removed this pterygopalatine mass and then sent this for pathology, then you may report code 61605 (Resection or excision of neoplastic, vascular or infectious lesion of infratemporal fossa, parapharyngeal space, petrous apex; extradural). Since this code (61605) does not include the surgical approach required to access the lesion, we need to report a code for the approach, which is endoscopic here. But if only the biopsy has been done, then there is no specific CPT code for endoscopic biopsy of pterygopalatine mass. In that case, you should bill unlisted code as suggested by you.
Please feel free to write if you have any question.