| Clinical Indicators
Endoscopic Debridement/Exam, Following Endoscopic Sinus
Surgery
| Procedure |
CPT |
FUD |
| Endoscopy with biopsy, polypectomy, or
debridement |
31237 |
0 |
| Endoscopy diagnostic, unilateral or bilateral
(separate procedure) |
31231 |
0 |
Indications
1. History...one or more required after failure of mechanical therapy
| a) |
Postoperative care of endoscopic sinus surgery |
| b) |
Postoperative hemorrhage |
| c) |
Postoperative exudate or discharge |
| d) |
Complications of sinus surgery |
| e) |
Fungal sinusitis |
2. Physical Examination
| a) |
Complete anterior and posterior nasal examination (rhinoscopy
after mucosal decongestion)(one or more required)
- Significant (early or late) scar formation, particularly in the region of
the middle meatus or the frontal recess
- Significant granulation, persistent crusting, or polypoid tissue,
unresponsive to medical therapy
|
Postoperative Observations
| 1. |
Bleeding, eyelid ecchymosis |
| 2. |
Pain - severe headache |
| 3. |
Vision - if there is loss of vision or double vision? |
| 4. |
Is there evidence of CSF leak? Rhinorrhea? |
Outcome Review
1. One Week
| a) |
Healing – Is surgical site healing satisfactorily? Did
patient require treatment for bleeding or infection? Is there persistent
crusting? |
| b) |
Are there any indications for CSF rhinorrhea? |
Associated ICD-9 Diagnostic Codes
| 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 sphenoidal sinusitis |
| 473.8 |
Chronic sinusitis NEC; pansinusitis |
| 478.1 |
Cyst or Mucocoele of sinus |
| 242.00 |
Thyrotoxicosis with or without goiter |
| 242.01 |
Toxic diffuse goiter with mention of thyrotoxic crisis or
storm |
| 376.32 |
Orbital hemorrhage |
| 376.33 |
Orbital edema |
| 921.2 |
Contusion of orbital tissues |
Additional Information
Assistant Surgeon -- N
Supply Charges -- N
Anesthesia Code(s)
00160
Patient Information
Following endoscopic sinus surgery procedures, your surgeon will monitor the
healing to provide the greatest assurance that the sinuses will remain healthy.
This evaluation includes examination of the interior of the nose and the region
where sinus surgery was performed. Your surgeon may recommend examining these
areas of the nose with a rigid or flexible scope one or more times after
surgery. At times, a localized cleaning (debridement) of the area may also be
performed. The decision regarding these procedures depends on your surgeon's
assessment of healing and your health. These examinations and/or procedures are
comfortably performed in the physicians office and may use topical or general
anesthesia (except for young children) and allow the patient to continue normal
activity immediately following the procedure.
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.
|