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Question Sinonasal Inverting Papilloma

MsAnna

Networker
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39
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Vancouver, WA
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Greetings all,
I was wondering what CPT code is being used for this? It was performed with endoscopic approach . I'm looking at 30117 but our provider wants to use skull base comparable codes as he calls this "Anterior skull base tumor" but It appears this is confined to nasal cavity and sinuses.



Any suggestions would be greatly appreciated. Thank you
 

MsAnna

Networker
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Vancouver, WA
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Greetings Barbara,
Any help you can provide is appreciated.

DESCRIPTION OF OPERATION: The patient was taken to the operating room and placed supine on the operating table. General endotracheal anesthesia was induced without difficulty. The patient was prepped and draped in the usual sterile fashion. Stereotactic navigation registration was performed given the nature of the case. Zero-degree rigid endoscopy was performed.

The right middle turbinate was resected using curved endoscopic scissors. Complete anterior and posterior ethmoidectomies were performed using the microdebrider and taken posterior to the sphenoid rostrum. The sphenoid os was identified and widely opened. There was noted to be polypoid tissue here, which was removed. The air cells were taken along the skull base from posterior to anterior. Agger nasi cell was taken down using upbiting forceps. There was noted to be pus in the frontal sinus. This was cultured. The maxillary os was identified and widely opened using upbiter and cutting forceps. There was noted to be edematous tissue here, which was removed. There was noted to be polypoid tissue within the right frontal sinus. Frozen section was consistent with inverting papilloma, moderate dysplasia.

Given that this was the case, the anterior aspect of the frontal recess was then widely drilled as well using a high-speed cutting bur. A partial septectomy was taken at the skull base, just inferior to the frontal sinus floor. This was then widely drilled across through the midline to the contralateral side. There was noted to be quite a bit of pus throughout the frontal sinus. This was all irrigated with antibiotic solution.

Attention was next turned toward the left side. There was diffuse nasal polyposis and inverting papilloma throughout. This was all removed. The residual middle turbinate was resected using curved endoscopic scissors. Complete anterior and posterior ethmoidectomies were taken using microdebrider, taken posterior to the sphenoid rostrum. The sphenoid os was identified and widely opened. There was noted to be edematous tissue here, which was removed. There was noted to be inverting papilloma grossly involving the skull base and lamina. All the mucosa was peeled off of the lamina and skull base anteriorly to the frontal sinuses. The agger nasi cell was taken down using upbiting forceps. This was then widely drilled away and connected with endoscopic Lothrop on the contralateral side. The intersinus septum was then widely drilled away superiorly to the reaches of the curved drill.

There was some tumor along the bony edges of which the mucosa was removed. The bone was then widely drilled away within the frontal sinus as well, especially laterally. There was noted to be hyperostotic bone, all of the lamina papyracea. This was then all widely drilled away until there was a thin layer of lamina left. There was gross total resection of tumor in these areas. The orbital floor was then drilled away medially as well. The mid portion of the inferior turbinate was resected. Endoscopic medial maxillectomy was then performed using the high-speed drill after this for clearance.

The ethmoid roof was then gently drilled away from the sphenoid sinus anteriorly to the frontal sinus. The anterior and posterior ethmoid arteries were encountered and controlled using Bovie electrocautery. Firm Nasopore packs were placed in both ethmoid cavities. The operation was terminated at this time. The patient was awakened from general anesthesia and extubated. The patient was taken to the recovery room in stable condition.
 
Messages
225
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Niantic, CT
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Yes I do. I've been watching this everyday. Any help you can provide I would be so greatful.
No problem, I took notes while reading the op note, give me a little time, look for my response either this evening or tomorrow, no problem! Happy to help!

Jennifer
Coding Analyst
 
Messages
225
Location
Niantic, CT
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No problem, I took notes while reading the op note, give me a little time, look for my response either this evening or tomorrow, no problem! Happy to help!

Jennifer
Coding Analyst

OK, this is what I came up with, interesting as the endoscopic codes have changed as of last year or the year before, anyway, they have bundled some of them, geez!

31225 (or 31299) - Medial Maxillectomy (left inferior turb resection bundled), this was performed endoscopically
31253 - 50, 22, 51 - Bil. Total Ethmoidectomies (Ant/Post) with Frontal Exploration & Tissue Removal
31288 - 50, 22, 51 - Bil. Spenoidotomy w/Tissue Removal
31267 - 51 - Rt. Maxillary Antrostomy w/Tissue Removal
61782 - Stereotactic Computer Assisted Navigational Procedure (add on code, no mod. required)

CPT 31225 is a "excisional" code as the approach is described as intra-oral, your surgeon performed it endoscopically and there is no code representative of this. If you are uncomfortable with the use of this code you can utilize 31299 - unlisted procedure of accessory sinuses and use 31225 as your comparative code to support the complexity of the procedure. Also note I added modifier 22 due to the complexity of the total ethmoidectomies, frontal sinusotomies, and sphenoidotomies. Inverted Papillomas of the Nasal Cavities, though benign, are invasive and the resection is time consuming and complicated, the surgeon is working in the skull base hence the necessity of the stereotactic navigation system. This was not a straightforward endoscopic sinus surgery and your surgeon should be paid reflecting the complexity of this service. Your surgeon should include a special report for the use of modifier 22 with the claim (or addend the operative report) that explains the complex nature of this procedure and why they should be paid at an increased rate accordingly. I understand your surgeon wants to use "skull based" procedures but there are no such codes presently for an "endoscopic approach" (only one for a pituitary tumor) the skull based surgical codes are all identified as external approaches with definitive procedures and repairs and therefore cannot be used.

Karen Zuptko & Assoc. - Kimberley Pollack has written about this, here a few links for your review.
https://www.thieme-connect.de/products/ejournals/abstract/10.1055/s-0039-1677682?utm_source=TrendMD&utm_medium=cpc&utm_campaign=Journal_of_Neurological_Surgery_Part_B%3A_Skull_Base_TrendMD_0

https://www.thieme-connect.de/products/ejournals/abstract/10.1055/s-0039-1677683?utm_source=TrendMD&utm_medium=cpc&utm_campaign=Journal_of_Neurological_Surgery_Part_B%3A_Skull_Base_TrendMD_0

See if you can reach out to Barbara Cobuzzi, she knows ENT forwards and backwards and I respect her opinion if you want to validate my coding of this surgery, I would be interested in what she thinks as well, LOL! The one thing I always tell other coders is you have to be able to defend and support your coding choices as there are a lot of gray areas in coding and it can be challenging.

Hope this helps!

Jennifer
Coding Analyst
 

MsAnna

Networker
Messages
39
Location
Vancouver, WA
Best answers
0
OK, this is what I came up with, interesting as the endoscopic codes have changed as of last year or the year before, anyway, they have bundled some of them, geez!

31225 (or 31299) - Medial Maxillectomy (left inferior turb resection bundled), this was performed endoscopically
31253 - 50, 22, 51 - Bil. Total Ethmoidectomies (Ant/Post) with Frontal Exploration & Tissue Removal
31288 - 50, 22, 51 - Bil. Spenoidotomy w/Tissue Removal
31267 - 51 - Rt. Maxillary Antrostomy w/Tissue Removal
61782 - Stereotactic Computer Assisted Navigational Procedure (add on code, no mod. required)

CPT 31225 is a "excisional" code as the approach is described as intra-oral, your surgeon performed it endoscopically and there is no code representative of this. If you are uncomfortable with the use of this code you can utilize 31299 - unlisted procedure of accessory sinuses and use 31225 as your comparative code to support the complexity of the procedure. Also note I added modifier 22 due to the complexity of the total ethmoidectomies, frontal sinusotomies, and sphenoidotomies. Inverted Papillomas of the Nasal Cavities, though benign, are invasive and the resection is time consuming and complicated, the surgeon is working in the skull base hence the necessity of the stereotactic navigation system. This was not a straightforward endoscopic sinus surgery and your surgeon should be paid reflecting the complexity of this service. Your surgeon should include a special report for the use of modifier 22 with the claim (or addend the operative report) that explains the complex nature of this procedure and why they should be paid at an increased rate accordingly. I understand your surgeon wants to use "skull based" procedures but there are no such codes presently for an "endoscopic approach" (only one for a pituitary tumor) the skull based surgical codes are all identified as external approaches with definitive procedures and repairs and therefore cannot be used.

Karen Zuptko & Assoc. - Kimberley Pollack has written about this, here a few links for your review.
https://www.thieme-connect.de/products/ejournals/abstract/10.1055/s-0039-1677682?utm_source=TrendMD&utm_medium=cpc&utm_campaign=Journal_of_Neurological_Surgery_Part_B%3A_Skull_Base_TrendMD_0

https://www.thieme-connect.de/products/ejournals/abstract/10.1055/s-0039-1677683?utm_source=TrendMD&utm_medium=cpc&utm_campaign=Journal_of_Neurological_Surgery_Part_B%3A_Skull_Base_TrendMD_0

See if you can reach out to Barbara Cobuzzi, she knows ENT forwards and backwards and I respect her opinion if you want to validate my coding of this surgery, I would be interested in what she thinks as well, LOL! The one thing I always tell other coders is you have to be able to defend and support your coding choices as there are a lot of gray areas in coding and it can be challenging.

Hope this helps!

Jennifer
Coding Analyst
Thank you so very much Jennifer. I really appreciate you spending the time to do this. I really appreciate you!
 

b.cobuzzi

Guru
Messages
199
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Sorry that I was absent. For some reason my computer would not let me log onto the forums. It is fixed now, like magic.
I agree with your analysis, JackJones62 and I would use 31299 for the endoscopic maxillectomy, equating it 31225, but possibly more than 100% of 31225. The endoscopic procedure is less invasive, providing for quicker healing, but more complex to accomplish. Ask your doctor where he/she would put the endoscopic maxillectomy versus the open maxillectomy. It might be 125% of the value of 31225 or more, but that is a call from your doctor.

As for the 22 modifiers, the increased service, you would be increasing those services also. These procedures, with how much of the frontal sinus is drilled out as well as the ethmoid and sphenoid sinuses, I would go with 150% of a normal FESS when pricing it and for your comments in box 19. State that the 22 modified procedures are increased complexity and risk for the patient due to the invasive nature of the inverting papilloma, causing 50% more work and risk than a normal endoscopic Frontal, ethmoidectomy and sphenoid sinusotomy would require in box 19 and increase your fee for each by 50%.

You can explain to your doctor that if you were taking out a skull base tumor like a pituitary, only the 62165 can be coded and as all the work in the sinuses represent the approach to the pituitary mass. And 62165 is usually performed as a co-surgery with a neurosurgeon. The way it is coded here, he is benefiting significantly more.
 
Messages
225
Location
Niantic, CT
Best answers
0
Sorry that I was absent. For some reason my computer would not let me log onto the forums. It is fixed now, like magic.
I agree with your analysis, JackJones62 and I would use 31299 for the endoscopic maxillectomy, equating it 31225, but possibly more than 100% of 31225. The endoscopic procedure is less invasive, providing for quicker healing, but more complex to accomplish. Ask your doctor where he/she would put the endoscopic maxillectomy versus the open maxillectomy. It might be 125% of the value of 31225 or more, but that is a call from your doctor.

As for the 22 modifiers, the increased service, you would be increasing those services also. These procedures, with how much of the frontal sinus is drilled out as well as the ethmoid and sphenoid sinuses, I would go with 150% of a normal FESS when pricing it and for your comments in box 19. State that the 22 modified procedures are increased complexity and risk for the patient due to the invasive nature of the inverting papilloma, causing 50% more work and risk than a normal endoscopic Frontal, ethmoidectomy and sphenoid sinusotomy would require in box 19 and increase your fee for each by 50%.

You can explain to your doctor that if you were taking out a skull base tumor like a pituitary, only the 62165 can be coded and as all the work in the sinuses represent the approach to the pituitary mass. And 62165 is usually performed as a co-surgery with a neurosurgeon. The way it is coded here, he is benefiting significantly more.

Thank you Barbara, I had an issue with accessing the Forum as well at one time and discovered it had to do with my using Explorer vs. Chrome, Explorer did not open all the elements of AAPC LOL, silly me. Thank you again for your input, I have always appreciated your coding knowledge and insight!

Jennifer
Coding Analyst
 
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