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Endoscopic Ethmoidectomy

  1. #1
    Default Endoscopic Ethmoidectomy
    Medical Coding Books
    Doctor listed right side endoscopic ethmoidectomy which he describes in the body of the op report as "the ethmoid sinuses were opened widely and extended into the sphenoid".

    Is this sufficient documentation to code an ethmoidectomy?

    Thanks for you input.

  2. #2
    Default
    I would suggest you have your provider be a bit more specific on his documentation. Ethmoidectomy indicates removal of tissue, which is not clearly documented in that one line. It seems to only document that the ethmoids were entered.

  3. Default
    Key words here are "opened widely and extended into the spenoid", yes, sufficient enought to bill total ethmoidectomy, as they indicated the ethmoid sinuse(s), pleural (anterior/posterior) and the only way to get into the spenoid is thru the posterior ethmoid. Go to You-Tube and watch a sinus surgery, you will get a better understanding of what you are dealing with.

    Jennifer
    ENT CT

  4. #4
    Default
    I appreciate the input and the viewing suggestion. Thanks.

  5. #5
    Default
    I understand, i may not have explained it as well as i am confused.

    if a pt comes in to our Urgent Care for ear pain, then the 69210 was done w/ an RX given would we add the 25 mod to the E/M?

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