Sinusitis also called rhinosinusitis or sinus infection is a common inflammation of the air cavities that produce the mucus necessary for the nasal passages to work properly. It is one of the more prevalent chronic illnesses in the United States and affects people of all ages. According to the Centers for Disease Control and Prevention (CDC), 26.5 million adults (11.0% of adults) were diagnosed with sinusitis in 2016. Sinusitis can be acute or chronic, and caused by viruses, bacteria, fungi, allergies, or even an autoimmune reaction. Surgery is generally recommended for chronic sinusitis when medical treatment fails. Frequently performed in an outpatient setting, functional endoscopic sinus surgery (FESS) is a minimally procedure used to restore sinus ventilation and normal function. There are new bundled FESS codes in 2018 and outsourcing medical coding can help providers understand the new codes and submit accurate claims for maximum reimbursement.
Chronic Rhinosinusitis (CRS) – Causes and Symptoms
While acute sinusitis usually occurs due to a bacterial infection and responds to antibiotics, chronic sinusitis triggers an aggressive inflammatory reaction and may not get better with conservative treatment. In CRS, the cavities around sinuses become inflamed and swollen for at least 12 weeks, and do not get better with treatment. Patient history is very important in CRS because sinus symptoms may be similar to that of other disease processes, and also due to the poor association between symptoms and endoscopic and radiographic findings.
Chronic sinusitis can be caused by an infection, by nasal polyps, or by a deviated nasal septum. Common symptoms are:
- Nasal obstruction, blockage, congestion, stuffiness
- Nasal discharge (which may be thin to thick and from clear to purulent)
- Postnasal drip
- Pain, tenderness and swelling around the eyes, cheeks, nose or forehead
- Chronic unproductive cough (especially in children)
- Hyposmia or anosmia (more with nasal polyps)
- Reduced sense of smell
- Sore throat
- Bad breath
- Fatigue or irritability
- Anorexia
- Exacerbation of asthma
- Dental pain (upper teeth)
- Visual disturbances
- Sore throat
- Stuffy ears
- Fever
Complications of a sinus infection that can occur include meningitis, brain abscess, osteomyelitis, and orbital cellulitis. Rare fungal infections of the sinuses are medical emergencies.
Diagnosis and Treatment
Symptoms must have been present for longer than 12 weeks for a diagnosis of chronic sinusitis. The following methods for diagnosing the condition:
- Examination of the nose and face for signs of tenderness
- Rhinoscopy (nasal endoscopy)
- Nasal and sinus cultures may be used to determine if the condition is caused by bacteria or fungi.
- An allergy skin test is done if thenasal flare up is suspected to be triggered by allergies
The goal of treating chronic sinusitis is to reduce the inflammation of the nasal passages and keep them draining, resolve the underlying cause, and reduce the incidence of sinusitis flare-ups. Primary treatments may include: saline nasal irrigation, nasal corticosteroids, corticosteroids, aspirin desensitization treatment, antibiotics, and immunotherapy. Functional endoscopic sinus surgery (FESS) could be an option for cases resistant to primary treatment.
Functional Endoscopic Sinus Surgery (FESS)
The goal of FESS is usually to remove obstructions that block natural drainage and also inflamed tissue and bone. FESS involves inserting an endoscope into the nose to evaluate the nasal anatomy, central airway, and sinuses. Abnormal and obstructive tissues are then removed or the septum straightened using state-of-the-art imaging technology and equipment. This less invasive surgical procedure is usually performed entirely through the nostrils, resulting in minimal post-operative discomfort, quicker healing.
The surgery may take from one to three or more hours, and the patient may receive general anesthesia or, sometimes, sedation through local anesthesia. Endoscopic sinus surgery can clear blockage with minimal disturbance to the healthy tissue and with no external scars.
Clinical Documentation to indicate Medical Necessity
For reimbursement, the clinical documentation must indicate the medical necessity of FESS. United Healthcare considers Functional endoscopic sinus surgery (FESS) as proven and/or medically necessary for one or more of the following:
- Patients with chronic rhinosinusitis (defined as rhinosinusitis lasting longer than 12 weeks) with both of the following:
- Chronic rhinosinusitis of the sinus to be operated on is confirmed on computed tomography (CT) scan by one or more of the following: Mucosal thickening; Bony remodeling; Bony thickening; Obstruction of the ostiomeatal complex, and Opacified sinus.
- Symptoms persist despite medical therapy with one or more of the following: Nasal lavage; Antibiotic therapy, if bacterial infection is suspected, and Intranasal corticosteroid
- Mucocele documented on CT scan
- Concha bullosa documented on CT scan
- Complications of sinusitis such as abscess
- Tumor documented on CT scan (such as polyposis or malignancy)
- Recurrent acute rhinosinusitis (RARS)
Reporting FESS
ICD Codes for sinusitis
ICD-10-CM sinusitis codes include diagnosis codes for acute recurrent sinusitis:
- B47.0 Eumycetoma
- C30.0 Malignant neoplasm of nasal cavity
- C31.0 Malignant neoplasm of maxillary sinus
- C31.1 Malignant neoplasm of ethmoidal sinus
- C31.2 Malignant neoplasm of frontal sinus
- C31.3 Malignant neoplasm of sphenoid sinus
- C31.8 Malignant neoplasm of overlapping sites of accessory sinuses
- C31.9 Malignant neoplasm of accessory sinus, unspecified
- D14.0 Benign neoplasm of middle ear, nasal cavity and accessory sinuses
- G96.0 Cerebrospinal fluid leak
- J01.01 Acute recurrent maxillary sinusitis
- J01.11 Acute recurrent frontal sinusitis
- J01.21 Acute recurrent ethmoidal sinusitis
- J01.31 Acute recurrent sphenoidal sinusitis
- J01.41 Acute recurrent pansinusitis
- J01.81 Other acute recurrent sinusitis
- J01.91 Acute recurrent sinusitis, unspecified
- J32.0 Chronic maxillary sinusitis
- J32.1 Chronic frontal sinusitis
- J32.2 Chronic ethmoidal sinusitis
- J32.3 Chronic sphenoidal sinusitis
- J32.4 Chronic pansinusitis
- J32.8 Other chronic sinusitis
- J32.9 Chronic sinusitis, unspecified
- J33.0 Polyp of nasal cavity
- J33.1 Polypoid sinus degeneration
- J33.8 Other polyp of sinus
- J33.9 Nasal polyp, unspecified
- J34.1 Cyst and mucocele of nose and nasal sinus
- J34.81 Nasal mucositis (ulcerative)
- J34.89 Other specified disorders of nose and nasal sinuses
- J34.9 Unspecified disorder of nose and nasal sinuses
- Q01.1 Nasofrontal encephalocele
- R04.0 Epistaxis
CPT Codes
In 2018, new FESS codes have been introduced which bundle a total ethmoidectomy with both a frontal sinusotomy and a sphenoidotomy with and without removal of tissue. 2018 CPT also provides a new bundled code for frontal and sphenoid endoscopic balloon dilation:
- 31256-31288 Functional Endoscopic Sinus Surgery Family (previously 7 codes, now 11)
- 31295-31297 Balloon Sinuplasty Family (previously 3 codes, now 4)
FESS codes
- 31240 Nasal/sinus endoscopy, surgical; with concha bullosa resection
- 31253 Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including frontal sinus exploration, with removal of tissue from frontal sinus, when performed
- 31254 Nasal/sinus endoscopy, surgical with ethmoidectomy; partial (anterior)
- 31255 Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior)
- 31256 Nasal/sinus endoscopy, surgical, with maxillary antrostomy
- 31257 Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including sphenoidotomy
- 31259 Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including sphenoidotomy, with removal of tissue from the sphenoid sinus
- 31267 Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus
- 31276 Nasal/sinus endoscopy, surgical with frontal sinus exploration, including removal of tissue from frontal sinus, when performed
- 31287 Nasal/sinus endoscopy, surgical, with sphenoidotomy
- 31288 Nasal/sinus endoscopy, surgical, with sphenoidotomy; with removal of tissue from the sphenoid sinus
Balloon Sinus Dilation Codes
- 31295 Nasal/sinus endoscopy, surgical; with dilation of maxillary sinus ostium (e.g., balloon dilation), transnasal or canine fossa
- 31296 Nasal/sinus endoscopy, surgical; with dilation of frontal sinus ostium (e.g., balloon dilation)
- 31297 Nasal/sinus endoscopy, surgical; with dilation of sphenoid sinus ostium (e.g., balloon dilation)
- New/Bundled 31298 Nasal/sinus endoscopy, surgical; with dilation of frontal and sphenoid sinus ostia (e.g., balloon dilation)
New Sphenopalatine Artery Code
- 31241 Nasal/sinus endoscopy, surgical; with ligation of sphenopalatine artery
FESS Coding Guidance
An AAPC article on FESS coding provides some important guidance about FESS coding. To a question on coding when all four sinuses are operated on the same side (with no removal of tissue), expert physicians advised:
- using CPT codes 31253, 31287, 31256 or 31257, 31276, 31256 to code all four sinuses
- If tissue is removed, 31287 and/or 31256 should be replaced with 31288 and/or 31267 in the first coding combination or 31257 and/or 31256 should be replaced with 31259 and/or 31267
Partnering with an experienced otolaryngology medical billing and coding company is the best way to manage the challenges associated with reporting office visits as well as for surgical procedures related to disorders and diseases of the ear, nose, and throat. Experienced medical coders will review medical records carefully to assign the right codes and ensure maximum reimbursement for otolaryngology services.
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