Bill Posted Tue 12th of August, 2014 11:22:35 AM
Need advise on the following report please. Surgeon said he did 1) Endoscopic rt maxillary antrostomy w/removal of tissue 2) endoscopic rt anterior ethmoidectomy 3) endoscopic rt frontal sinusotomy
operative procedure states: Attention was first focused on the right side with operating endoscope. there was found to be polypoid tissue and significant purulent material draining from the middle meatus. This appeared to be primarily coming from the maxillary sinus. Using a cured seeker, the maxillary sinus was initially probed with expression of significant purulent material. (Cultures were sent) Following this, the microdebrider was used to remove the inferior and superior portions of the uncinate process, creating a wide antrostomy into the maxillary sinus. There was found to be dense fungal debris within the maxillary sinus along with hypertrophic mucosa and significant purulent material. This was carefully cleaned from the maxillary sinus. The base of the sinus was reached with a curved microdebrider blade, and inspected carefully using 30-degree and 70-degree scopes. Attention was then focused up in the anterior ethmoids. Significant polypoid mucosa and hyperemic mucosa was taken down primarily using the micordebrider as the anterior ethmoid cells were widely opened. The microdebrider was used to remove additional tissue around the nasal frontal duct. The frontal sinus was irrigated copiously as well.
My question is, does it sound to you like he really did a right frontal sinusotomy? I thought appropriate codes would be "31267" and "31254" only. does this sound right?
SuperCoder Answered Thu 14th of August, 2014 04:08:18 AM
Greetings for the day!
Based on the documentation provided in your query, correct codes are as follows (same as you had suggested)
31254- Endoscopic anterior ethmoidectomy
31267- Endoscopic maxillary antrostomy with tissue removal
We would not code 31276 for Frontal sinusotomy as exploration of frontal sinus is not performed. Although, tissue removal is documented but around nasal frontal duct which will not qualify for 31276 as frontal sinus was not probed for exploration or tissue removal. Irrigation done but does not qualify as exploration.
I hope it answers your query.
Bill Posted Fri 15th of August, 2014 09:50:42 AM
It sure does, thank you very much
SuperCoder Answered Fri 15th of August, 2014 09:56:20 AM