Question Ethmoidectomy with frontal sinus exploration


Baldwin Park, CA
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DX: right chronic sinusitis

1. right ethmoidectomy with frontal sinus exploration
2. right maxillary antrostomy with tissue removal

Using a 0-degree endoscope, bilateral nasal cavity was examined and purulence was noted to emanate from the right maxillary ostia. Approximately 10 cc of lidocaine with epinephrine was injected into the uncinate area on the right. Using a Cottle knife, an uncinectomy incision was made and the uncinate bone was taken down using a straight Blakesley. the maxillary antrostomy was then widened using a backbiting forceps. purulence was noted to emanate from the maxillary sinus and culture swabs were used to take cultures from the maxillary sinus. Additionally, edematous thickened tissue was removed from the maxillary sinus and sent to pathology labeled as maxillary content. After this was completed, as Acclarent balloon sinuplasty catheter was threaded through the frontal recess and the area was dilated x 3. Attention was then turned to the ethmoid sinus where the ethmoid bones were taken down using a straight Frazier tip suction. After this was completed, the procedure was concluded.

I assign 31267 - for removal tissue via maxillary

The highlighted performance qualified for the CPT 31253? I am confused because the surgeon did not indicate the ethmoidectomy was done for partial or total ( anterior + posterior). He only mentioned ethmoid bones were takedown.

Please advice. Thank you.


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Su Ye,

You need to ask the physician as the documentation is insufficient. The surgeon really needs to amend the op note and clarify what was performed in the ethmoid sinuses. This documentation is just not enough to code and not enough for an op note,

The frontal sinus was a balloon dilation. No tissue was removed, so even if a total ethmoidectomy was performed, the combination code of 31253 would not be coded as 31276 is no supported in the op note. The op not supports 31297 for a frontal sinus dilation.

So the coding will be:
31254-RT or 31255-RT depending on the corrected op note