Otolaryngology Coding Alert

Usually, an otolaryngologist operating alone will perform an endoscopic dacryocystorhinostomy (DCR). On occasion, however, an ophthalmologist may also be present during the operative session. Coding such a situation can be difficult because, according to the HCFA fee schedule, neither cosurgery (modifier -62) nor assistant surgery (modifier -80) should be coded when 31239 (nasal/sinus endoscopy, surgical; with dacryocystorhinostomy) is billed.

DCR reduces or eliminates tearing or recurrent infections of the lacrimal system of the eye. The procedure involves the construction of a new pathway for tears to exit the eye by way of an incision along the side of the nose that creates an opening in the nasal bone.

When DCR is performed endoscopically, dilators and/or a light probe is passed through the duct and small tubes, or stents, may also be inserted into the two drainage points of the eye and passed through the opening in the bone and into the nose.

Endoscopic DCR has significant advantages over external DCR, including absence of facial scarring. The patient may also require additional endoscopic procedures to treat inflamed sinuses or turbinates, which may be contributing to lacrimal problems.

Some otolaryngologists may not feel comfortable catheterizing the lacrimal system and may request that an ophthalmologist perform these functions, says Sanford Archer, MD, an otolaryngologist and associate professor at the University of Kentuckys College of Medicine in Lexington, Ky., chair of the Patient Safety and Quality Improvement Committee of the American Academy of Otolaryngology Head and Neck Surgeons (AAO-HNS) and a member of the academys Rhinology and Paranasal Sinus Committee.

When this occurs, coding and billing the operative session depends on the documentation in the operative report, which should be carefully examined to determine precisely what procedures each surgeon performed, as illustrated below.

Operative Report

Preoperative Dx: Obstructed left nasolacrimal system

Postoperative Dx: Obstructed left nasolacrimal system, sinus polyposis

Procedure: Endoscopic DCR on the left and a left anterior ethmoidectomy

Indications: 65-year-old male with a history of extensive sinus polyposis has had multiple sinus procedures and allergy shots in the past. He has had obstructive nasolacrimal system with chronic epiphora that has been refractory to [an ophthalmologist]s best medical management. He presents now for an endoscopic DCR on the left.

Procedure: The patient was brought to the operating room, placed under general endotracheal anesthesia. The ophthalmologist placed antibiotic drops in the left eye and probed the left lacrimal duct with serial dilators and then a light probe. I examined the nose endoscopically. He had extensive polyposis in the anterior ethmoid and cicatrix and scar along the lateral wall of the nose. The light probe could not initially be identified due to the covering polyposis. This was removed with the microdebrider after the [...]