| Clinical Indicators
Endoscopic Sinus Surgery, Adult
| Procedure |
CPT |
FUD |
| Endoscopy with ethmoidectomy, partial (anterior) |
31254 |
0 |
| Endoscopy with ethmoidectomy, total (anterior & posterior) |
31255 |
0 |
| Endoscopy with maxillary antrostomy |
31256 |
0 |
| Endoscopy with maxillary antrostomy and removal of tissue from maxillary
sinus |
31267 |
0 |
| Endoscopy with frontal sinus exploration, with or without removal of tissue
from sinus |
31276 |
0 |
| Endoscopy with sphenoidotomy |
31287 |
0 |
| Endoscopy with sphenoidotomy & removal of tissue from sphenoid
sinus |
31288 |
0 |
| Endoscopy with repair of cerebrospinal fluid leak, ethmoid region |
31290 |
10 |
| Endoscopy with repair of cerebrospinal fluid leak, sphenoid region |
31291 |
10 |
| Endoscopy with medial or inferior orbital wall decompression |
31292 |
10 |
| Endoscopy with medial and inferior orbital wall decompression |
31293 |
10 |
| Endoscopy with medial or inferior orbital wall decompression with
optic nerve decompression |
31294 |
10 |
Indications
1.History. . . one or more required
| a. |
Failure of medical management for chronic sinus pathology
(The history must include specific symptoms and findings obtained by the
otolaryngologist. A historical diagnosis labeled "sinusitis"
by the patient or unsubstantiated symptoms alone is not sufficient
documentation to establish this as a chronic illness). |
| SINUS SIGNS AND SYMPTOMS |
| Major Factors |
Minor Factors |
Facial pain/pressure*
Facial congestion/fullness
Nasal obstruction/blockage
Nasal discharge/purulence/discolored post nasal drainage
Hyposmia/amosmia
Purulence in the nasal cavity on examination
Fever (acute rhinosinusitis only)** |
Headache
Fever (all non-acute)
Halitosis
Fatigue
Dental pain
Cough
Ear pain/pressure/fullness |
* Facial pain/pressure alone does not constitute a suggestive history for
rhinosinusitis in the absence of another major nasal symptom or sign.
** Fever in acute sinusitis alone does not constitute a strongly suggestive
history for acute sinusitis in the absence of another major nasal symptom or
sign.
- Chronic disease is defined as sinusitis of greater than 12 weeks
duration that includes either two or more major sinus symptoms, or includes at
least one major and two minor sinus symptoms
- Clinically significant recurrent sinusitis is defined as 4 or more
episodes of acute sinusitis per year, each lasting greater than 7 - 10 days,
and there is absence of symptoms between episodes (without antibiotic
therapy)
| b. |
Complications of sinusitis, including extension to adjacent
structures |
| c. |
Multiple or recurrent polyps with airway obstruction |
| d. |
Mucocoele |
| e. |
Chronic anterior headache, caused by anatomic or pathologic
sinus disorder |
| f. |
Impaired sense of smell |
| g. |
Inverted papilloma or localized malignancy |
| h. |
CSF leak |
| i. |
Dacryocystorhinostomy |
| j. |
Orbital decompression |
| k. |
Repair of choanal atresia and nasal lacrimal duct
obstruction |
2. Physical Examination
| a. |
Complete anterior and posterior nasal examination (rhinoscopy
after mucosal decongestion) |
| b. |
Examination of nasopharynx (if possible) |
| c. |
Nasal endoscopic examination, obtained following medical
therapy |
3. Tests
| a. |
For surgical planning, coronal CT scan is required in
all cases following medical therapy. |
| b. |
Complete axial CT scan... required in cases with complex
disease. |
| c. |
Culture and sensitivity - optional. |
| d. |
Allergy testing. |
4. Optimal Medical Therapy: prior to obtaining sinus CT scan,
prior to nasal endoscopy, and prior to surgery
| a. |
Allergic evaluation and treatment when indicated |
| b. |
Decongestants when indicated |
| c. |
Topical and/or systemic steroids when indicated |
| d. |
Treatment of rhinitis medicamentosa, when present |
| e. |
Education on environmental irritants including tobacco
smoke |
| f. |
Antibiotic therapy consisting of four to six consecutive
weeks of appropriate antibiotic drugs |
5. Surgical Procedure and Findings:
| a. |
Must be compatible with clinical status, CT findings, and nasal
endoscopic findings. That is, only patients with significant persistent
sinus symptoms and pathology should undergo surgery. |
Post-Operative Observations
| 1. |
Bleeding, eyelid ecchymosis; notify surgeon |
| 2. |
Pain - severe headache; notify surgeon |
| 3. |
Packing - was middle meatal packing sufficient? Is it in
desired location? |
| 4. |
Vision - if there is loss or double vision, notify surgeon
immediately |
| 5. |
Swelling - is there evidence of facial edema? If hematoma,
notify surgeon |
| 6. |
Mental status - is patient alert and oriented? If not, notify
surgeon |
Outcome Review
1. One Week
| a. |
Healing - Did patient require treatment for bleeding or
infection? Is surgical site healing satisfactorily? |
| b. |
Did patient require one or more episodes of debridement? |
| c. |
Pathology - Does the pathology report indicate need for further
treatment and if so, how managed? |
| d. |
Are there any indications for CSF leak rhinorrhea? |
2. Beyond One Month
| a. |
Presenting problem - are persisting sinus symptoms
improved? |
| b. |
Airway - Is there evidence of airway obstruction due to polyps
or nasal crusting? |
| c. |
Are there any indicators for CSF rhinorrhea? |
Associated ICD-9 Diagnostic Codes
| 160.2 |
M-Neoplasm, Maxillary sinus |
| 160.3 |
M-Neoplasm, Ethmoid sinus |
| 160.4 |
M-Neoplasm, Frontal sinus |
| 160.5 |
M-Neoplasm, Sphenoid sinus |
| 194.3 |
M-Neoplasm, Pituitary gland |
| 212.0 |
B-Neoplasm, Nasal cavity/sinus |
| 231.8 |
CA in situ, Respiratory system NEC |
| 235.9 |
UB-Neoplasm, Respiratory system NOS |
| 349.81 |
Cerebrospinal fluid rhinorrhea |
| 376.01 |
Orbital cellulitis, abscess |
| 461.1 |
Acute frontal sinusitis |
| 471.1 |
Polypoid sinus degeneration |
| 471.8 |
Nasal sinus polyp NEC |
| 473.0 |
Chronic maxillary sinusitis |
| 473.1 |
Chronic frontal sinusitis |
| 473.2 |
Chronic ethmoidal sinusitis |
| 473.3 |
Chronic spheroidal sinusitis |
| 473.8 |
Chronic sinusitis NEC; pansinusitis |
| 478.1 |
Cyst or Mucocoele of sinus |
| 242.0 |
Graves disease/exophthalmopathy without thyrotoxicosis |
| 242.0 |
Graves disease/exophthalmopathy without thyrotoxicosis |
| 376.32 |
Orbital hemorrhage |
| 376.33 |
Orbital edema |
| 921.2 |
Contusion of orbital tissues |
Additional Information
Assistant Surgeon - N
Supply Charges - Not Allowed
Anesthesia Code(s)
00160
Patient Information
Endoscopic sinus surgery is performed through an intra nasally and is
recommended only after it has been determined that medical management has been
unsuccessful. Surgery, medical management, and failure to intervene all have
risks, including as a group, postoperative bleeding, orbital complications
(visual impairment), intracranial extension (brain damage or infection),
leakage of cerebrospinal fluid, persistent or recurrent nasal obstruction due
to failure to manage polyps and recurrent nasal or sinus infections.
Radiographs and endoscopic findings considered in conjunction with the
patients clinical status - following medical evaluation and therapy - will
identify the appropriate sinuses to treat.
Important Notice
The Clinical Indicators for Otolaryngology--Head and Neck Surgery
are guidelines only. In no sense do they represent a standard of care. The
applicability of an indicator for a procedure, and/or of the process or outcome
criteria, must be determined by the responsible physician in light of all the
circumstances presented by the individual patient. Adherence to these
guidelines will not ensure successful treatment in every situation. The
American Academy of Otolaryngology-Head and Neck Surgery, Inc. emphasizes that
these clinical indicators should not be deemed inclusive of all proper
treatment decisions or methods of care, nor exclusive of other treatment
decisions or methods of care reasonably directed to obtaining the same
results.
© 2000 American Academy of Otolaryngology-Head and Neck Surgery.
One Prince Street, Alexandria, VA 22314.
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