Wiki Help! Nasolacrimal Duct cyst

[AN2114]

I'm hoping for some help because I'm having a hard time with this report. The doctor did a marsupialization of bilateral nasolacrimal duct cysts, bilateral inferior turbinate outfracture, and nasal dilation. He wants me to code 68720 which is for a Dacryocystorhinostomy, 30930 for the outfracture turbinates, and 31231 for a nasal endoscopy. I feel like from what I read in the procedure and my research with the dacryocystorhinostomy, it doesn't sound like that would be the correct code. Unless does that code include marsupialization of nasolacrimal duct cysts and the outfracture turbinates? I can't find any code either for the marsupialization of the nasolacrimal duct cysts, so I'm torn on what the correct coding is for this procedure. Below I have the op report in case it helps to see.

Preop DX: Bilateral Nasolacrimal Duct Cysts
Post op DX: Same

Procedure: Marsupialization of bilateral nasolacrimal duct cysts, bilateral inferior turbinate outfracture, nasal dilation.

Procedure Details: Patient was brought back to the OR initially under the care of the anesthesia team. General anesthesia was administered and the patient was intubated. Afrin soaked pledgets were placed in the bilateral nasal cavities. The bilateral inferior turbinates were then injected with 1.5 cc of 1% lidocaine with 1:100,000 epinephrine total. The left side was evaluated first. Using a nasal endoscope, the inferior turbinate was then infractured using a freer. A cystic mass was found inferior to the inferior turbinate overlying the nasolacrimal duct. The XPS was then used to debride the cyst. Once the cyst was completely marsupialized, the inferior turbinate was then outfractured. The same procedure was then performed on the right side. After the cysts were removed, nasal dilators were used to progressively dilate the nasal cavity. The endoscope was used to again evaluate the nasal cavity and hemostasis was confirmed and the airway was widely patent. This concluded the procedure. The patient was returned to the care of the anesthesia team. The patient tolerated the procedure well.

 

[cpc2007]

This is definitely an unusual case. I would not code a dacrocystorhinostomy because that procedure involves creating a new passage between the tear duct and the nasal cavity when the tear duct becomes blocked. Normally they will excise a small amount of bone to create that new connection between the two structures and that doesn't occur here. It sounds to me like the surgeon debrided and opened up a cyst that was blocking the native tear duct and then marsupialized the edges to prevent regrowth and obstruction of the tear duct. So he is clearing out an obstruction of the existing passageway to the nasal cavity rather than creating a new passageway for the duct to drain.

With that in mind, I would report unlisted code 68899 since there is no code for marsupializing a cyst/lesion of the nasolacrimal duct. For pricing, I would consider comparing the unlisted to code 31239 which is for an endoscopic dacrocystorhinostomy (since he is using endoscopic visualization/dilatation at points in the procedure to completely open this existing passageway). I agree with 30930 for the outfracture of the inferior turbinates and would add modifier 50 since that procedure occurred bilaterally. 31231 would not be reported separately since it's part of the approach/visualization for the main procedure.

I hope that helps -have a great night

Kim
www.codingmastery.com

 

[AN2114]

This is definitely an unusual case. I would not code a dacrocystorhinostomy because that procedure involves creating a new passage between the tear duct and the nasal cavity when the tear duct becomes blocked. Normally they will excise a small amount of bone to create that new connection between the two structures and that doesn't occur here. It sounds to me like the surgeon debrided and opened up a cyst that was blocking the native tear duct and then marsupialized the edges to prevent regrowth and obstruction of the tear duct. So he is clearing out an obstruction of the existing passageway to the nasal cavity rather than creating a new passageway for the duct to drain.

With that in mind, I would report unlisted code 68899 since there is no code for marsupializing a cyst/lesion of the nasolacrimal duct. For pricing, I would consider comparing the unlisted to code 31239 which is for an endoscopic dacrocystorhinostomy (since he is using endoscopic visualization/dilatation at points in the procedure to completely open this existing passageway). I agree with 30930 for the outfracture of the inferior turbinates and would add modifier 50 since that procedure occurred bilaterally. 31231 would not be reported separately since it's part of the approach/visualization for the main procedure.

I hope that helps -have a great night

Kim
www.codingmastery.com

Thank you!!

 

[cpc2007]

Thank you!!

You're welcome!