Take a Deep Look Inside Surgical Procedures for Turbinates
With a clear understanding of anatomy and treatment, coding is not as difficult as it seems.
Coding turbinate surgery looks simple, but looks can be deceiving — and certainly are in this case. How could something so small be so complicated? Let’s dive into the nuts and bolts of coding for turbinate surgery.
Know Your Nose Anatomy
The turbinates, or nasal conchae, are three scroll-like bones covered in mucosal tissue that project medially from the lateral wall on each side of the nasal cavity. They help warm and moisturize the air as it flows through the nose. The turbinate tissue is also covered by cilia, which clean the air as it moves through the nose and into the lungs.
There are three turbinates — inferior, middle, and superior — on each side of the nasal cavity. The superior and middle turbinates are processes of the ethmoid bone and cover the posterior ethmoid and maxillary sinuses. The inferior turbinates are facial bones, and direct most of the air that comes in through the nose.
Identify Indications for Surgery
Turbinate enlargement is caused by many factors such as allergies or other irritation, chronic sinus inflammation, or compensation from a deviated nasal septum. This can cause airflow blockage or a runny nose. Enlarged, or hypertrophied, turbinates may be treated by medication. If medication doesn’t work, surgery may be indicated.
Carve Out Surgical Techniques
To open airways, turbinates, mucosa or bone, can be reduced using turbinate reduction, turbinate resection, turbinoplasty, or turbinectomy. Common terms you will see in operative reports for these procedures include:
- Microdebrider resection
- Radiofrequency reduction
Sniff Out the Right Procedure Code
There are several CPT® codes to describe turbinate procedures. When selecting the appropriate CPT® code for turbinate surgery, you must determine the:
- Location of turbinate (inferior, middle, superior),
- Extent (partial or complete),
- Depth (superficial or submucosal),
- Tissue affected (bone or mucosa), and
- Technique used (ablation, excision, etc.).
Procedures on Inferior Turbinates
Surgical procedures performed on nasal inferior turbinates, which is most common, include excision, ablation, and outfracture. Look in the Surgery section, under Respiratory System, Nose (30000-30999) for the codes.
CPT® codes 30130 Excision inferior turbinate, partial or complete, any method and 30140 Submucous resection inferior turbinate, partial or complete, any method describe excising turbinate tissue.
In 30130, part or all of the inferior turbinate is excised at the base, removing all tissue layers of the turbinate, mucosa, and bone. Modifier 50 Bilateral procedure is used if this surgery is performed bilaterally. This procedure is rarely done because it removes the function of the turbinate and the cilia that is needed to fight infection, leaving the nasal cavity with dryness, crusting, and burning pain. Some patients experience a phenomenon called empty nose syndrome (secondary atrophic rhinitis), a disorder where the patient has a patent airway but describes poor nasal breathing.
CPT® 30140 describes submucous excision of the inferior turbinate where an incision is made in the mucosal layer of the turbinate and the tissue is lifted off the bone. Partial or complete excision of bone and/or the under surface of the mucosa is excised using a sharp instrument such as a microdebrider. The mucosal layer is then laid back down, reducing the size of the turbinate. This helps to preserve the lining of the turbinate and protect its function. Use modifier 50 if this surgery is performed bilaterally.
Ablation CPT® codes are:
30801 Ablation, soft tissue of inferior turbinates, unilateral or bilateral, any method (e.g., electrocautery, radiofrequency ablation, or tissue volume reduction); superficial
30802 intramural (ie, submucosal)
Codes 30801 and 30802 describe the same procedure, except 30801 is performed on the outer surface of the mucosal layer on top of the turbinate bone and 30802 is performed under the mucosal layer.
A device, such as a coblator, heats up the tissue and causes scar tissue to form and shrink the turbinate as it heals. Modifier 50 is not used on 30801 and 30802 because the code descriptor says “unilateral or bilateral.” These procedures are used when one or both interior turbinates are ablated.
The parenthetical notes for 30801 and 30802 state:
- Do not report 30801 with 30802.
- Do not report 30801, 30802, or 30930 with 30130 or 30140.
CPT® 30930 Fracture nasal inferior turbinate(s), therapeutic is where the thin turbinate bone within the mucosa is fractured using a blunt instrument and pushed out of the way (medialized) to open the nasal airway, creating a larger space for better breathing. Both CPT® and Medicare consider 30930 unilateral and allow modifier 50 when the procedure is performed bilaterally, even though the code description states “turbinate(s).”
Generally, the inclusion of the “s” in a code description means to report the code without a modifier when it is performed unilaterally or bilaterally, but that is not the case here, per CPT® Assistant July 2001, page 11, and July 2016, page 8.
CPT® and Medicare differ on the bundling relationship of 30802 and 30930. A National Correct Coding Initiative (NCCI) edit bundles 30802 (column 2) into 30930 (column 1).
In the September 2010 CPT® Assistant, page 9, the American Medical Association (AMA) states:
Code 30802, Ablation, soft tissue of inferior turbinates, unilateral or bilateral, any method (e.g., electrocautery, radiofrequency ablation, or tissue volume reduction); intramural (i.e., submucosal), is not bundled with code 30930, Fracture nasal inferior turbinate(s), therapeutic.
Check with insurance carriers to make sure the coding reflects their requirements.
Correction: An erratum published in CPT® Assistant (November 2017) rescinds previous guidance, stating, “… 30930 includes one or both inferior turbinates. Therefore, if therapeutic fracture of nasal turbinates is performed bilaterally, modifier 50 … should not be appended.”
Procedures on Superior and Middle Turbinates
When coding for procedures performed on the superior or middle turbinates, several CPT® parenthetical notes lead us to unlisted CPT® code 30999 Unlisted procedure, nose:
- For excision of superior or middle turbinate, use 30999.
- For submucous resection of superior or middle turbinate, use 30999.
- For ablation of superior or middle turbinate, use 30999.
- For fracture of superior or middle turbinate[s], use 30999.
CPT® directs us to use 31240 Nasal/sinus endoscopy, surgical; with concha bullosa resection when resecting concha bullosa of the middle turbinate: “For endoscopic resection of concha bullosa of middle turbinate, use 31240.”
A concha bullosa is an air-filled pocket that forms on the middle turbinate that can cause nasal obstruction. The surgeon inserts an endoscope into the nasal cavity and uses an instrument to excise the pocket.
During endoscopic sinus surgery, the middle turbinate bone may be moved out of the way to approach the ethmoid sinuses, a pair of air-filled spaces (paranasal sinuses) in the skull that surround the nose. This is not separately reported, as the middle turbinates are processes of the ethmoid bone and are removed to gain access to the sinuses.
Quick Recap of Turbinate Coding
|30130||Excises the partial or complete inferior turbinate, bone and mucosa using a blade||Does not spare the mucosa||Use modifier 50 for bilateral|
|30140||Resects the tissue under the mucosa (submucosal resection), generally using a blade or microdebrider||Spares the mucosa so it still functions||Use modifier 50 for bilateral|
|30801||Uses coblation to ablate the soft tissue of the inferior turbinate(s)||On the mucosa||No modifier 50|
|30802||Uses coblation to ablate the soft tissues under the mucosa (submucosal, intramural)||Under the mucosa||No modifier 50|
|30930||Fractures the inferior turbinate(s)||Fractures the turbinate bone||Use modifier 50 for bilateral|
|31240||Resects concha bullosa (middle turbinate air cell) using an endoscope||Endoscopic removal||Use modifier 50 for bilateral|
|30999||Unlisted procedure for middle or superior turbinate|
Rachel Briggs, CPC, CPMA, CRC, CEMC, CENTC, AAPC Fellow, has 25 years of healthcare experience as a coder, auditor, billing manager, and physician coding educator. She is a contributing editor and subject matter expert for coding and auditing textbooks. Briggs has served in various officer roles and is the education officer of the Columbus, Ohio, local chapter.
AMA, CPT® Assistant, July 2001, page 11; July 2016, page 8; September 2010, page 9
AMA, CPT® Assistant FAQ, July 16, Volume 26, Issue 7, pages 8-9