Today’s article will be dedicated to discussing the anatomy of the sinuses and to providing an overview of some of the key codes and guidelines in the sinus endoscopy section of CPT. There were some pretty sweeping changes to the sinus endoscopy codes in 2018, and those changes are still generating questions and confusion for physicians and coders alike on how these new codes were intended to be used.
Before we look at specific CPT codes and examples, let’s begin by reviewing the anatomy of the sinuses. Patients with normal anatomy have four sinuses in total. Each of these sinuses is “paired” with one sinus cavity on the left and the other on the right:
- Maxillary Sinus – The maxillary sinus is embedded in the upper portion of the maxillary bone (the upper jaw bone). It is the largest of the four sinus cavities and drains into the middle meatus. This sinus is sometimes referred to as the “antrum” or “antral” in operative reports so if you see these terms, know that they are referring to the maxillary sinus.
- Ethmoid Sinus – This sinus is located between the eyes close to the bridge of the nose. The ethmoid sinus is made up of smaller “air cells” (typically nine air cells in total). This sinus also has anterior air cells (which are closer to the entrance of the sinus) and posterior air cells (which are towards the back of the sinus cavity). This detail is important to know when coding procedures performed in this sinus as we will see in a moment.
- Sphenoid Sinus – The sphenoid sinus, as the name suggests, is embedded in the sphenoid bone. The sphenoid bone is one of the seven bones that help to form the eye socket. Because of its proximity to the optic nerve, disease in the sphenoid sinus can cause particular pain and sensitivity for patients.
- Frontal Sinus – Finally, the frontal sinus is located behind the eye and around the eyebrow. It is the most “superior” sinus (the sinus closest to the top of the head).
If you are a visual learner, check out this link which shows the sinuses labeled and in different colors: Picture of Sinuses. In this picture, the maxillary sinuses are orange, the ethmoid sinuses are green, the sphenoid sinuses are yellow, and the frontal sinuses are pink to help you distinguish where each sinus begins and ends.
While sinus surgery can be performed through an open approach (i.e., an incision into the skin/soft tissues of the face with an opening made into the bone to access the sinus), open procedures are really invasive. Therefore, sinus surgery is most often performed endoscopically. This article will focus on endoscopic sinus surgery only. When sinuses are accessed endoscopically, they are viewed through a scope inserted into the nasal cavity (the open space inside the nose that is accessible by entering through each nostril and eventually connects to the pharynx at the back of the cavity).
Now that we have the anatomy of the sinuses down, let’s talk about procedures that may be performed in the sinuses. This article will not cover all nasal/sinus endoscopy codes in CPT – we would need a comprehensive training module to go through all of the procedures that might be performed in the nasal cavity/sinuses, but my goal today is to focus on the most common procedures you will see and help you develop the skills you need to tell these procedures apart.
To start, I want to focus on procedures that are performed in individual sinuses with or without the removal of diseased tissue. After we look at the proper coding for procedures performed in an individual sinus, we will explore some combination codes that must be reported instead of the individual sinus codes when work in two of these sinuses is performed on the same side (e.g., left) during the same surgery.
Maxillary Sinus:
In the maxillary sinus, we have two codes for surgically creating an opening into maxillary sinus. The first code 31256 is reported for the work of a maxillary antrostomy only without removal of tissue while the second code 31267 includes removal of tissue from the maxillary sinus in addition to the maxillary antrostomy:
- CPT 31256: Nasal/sinus endoscopy, surgical, with maxillary antrostomy;
- CPT 31267: Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus
To break down the code definitions a little bit, the prefix antro- means “of or referring to the antrum” (i.e., the maxillary sinus) and the suffix –ostomy means “to form a new opening.” So a maxillary antrostomy again is the surgical creation of an opening into the maxillary sinus to help the sinus drain more effectively.
“Removal of tissue” in the context of CPT 31267 means using surgical tools such as scalpels, biters, forceps, etc. to remove solid tissue like inflamed mucosa and polyps from the sinus.
Coding tip: You should not report CPT 31267 or any other sinus surgery code that requires removal of tissue if the physician simply “suctions out” the sinus. This suctioning of purulent material/mucus does not meet the CPT definition of “removal of tissue.”
Ethmoid Sinus:
In the ethmoid sinus, we have two codes for excision of the air cells in the ethmoid sinus. CPT 31254 is reported for an anterior ethmoidectomy while CPT 31255 is reported for a total ethmoidectomy:
- CPT 31254: Nasal/sinus endoscopy, surgical, with ethmoidectomy; partial (anterior)
- CPT 31255: Nasal/sinus endoscopy, surgical, with ethmoidectomy; total (anterior and posterior)
To break down the code definitions a little bit, the prefix ethmoid- means “of or pertaining to the ethmoid sinus” while the suffix –ectomy means “to excise.” So an ethmoidectomy is a procedure to excise the air cells that form the ethmoid sinus. The difference in these two codes is that CPT 31254 is coded for excision of the anterior air cells only (which is a partial excision) while CPT 31255 is coded for excision of anterior and posterior air cells (which is a total excision).
Sphenoid Sinus
In the sphenoid sinus, as we saw with the codes for the maxillary sinus, we have two codes for surgically creating an opening into the sphenoid sinus. The first code 31287 is reported for the work of a sphenoidotomy only without removal of tissue while the second code 31288 includes removal of tissue from the sphenoid sinus in addition to the sphenoidotomy:
- CPT 31287: Nasal/sinus endoscopy, surgical, with sphenoidotomy;
- CPT 31288: Nasal/sinus endoscopy, surgical, with sphenoidotomy; with removal of tissue from the sphenoid sinus
To break down the code definitions a little bit, the prefix sphenoid- means “of or pertaining to the sphenoid sinus” while the suffix – otomy means “to open.” So even though this word ends in “otomy” instead of “ostomy” which is the suffix we encountered with the maxillary antrostomy, a sphenoidotomy is still a procedure to open up the sphenoid sinus and help it to drain more effectively.
“Removal of tissue” in the context of CPT 31288 also means using surgical tools such as scalpels, biters, forceps, etc. to remove solid tissue from the sinus like inflamed mucosa and polyps in the sinus. You should not code 31288 for “suctioning” of the sinus only.
Frontal Sinus:
Finally, we have only one code for entering into and/or removing diseased tissue from the frontal sinus.
- CPT 31276: Nasal/sinus endoscopy, with frontal sinus exploration, including removal of tissue from the frontal sinus, when performed
To break down the code definition a little bit, unlike CPT codes 31256 or 31287 which mention an otomy or ostomy (creation of an opening into the sinus), this code states “with frontal sinus exploration.” However, if you read the lay description of CPT 31276 from tools like the Coder’s Desk Reference or Encoder Pro, CPT 31276 describes making a “sinusotomy” into the frontal sinus (opening up the frontal sinus). Therefore, the intent of CPT 31276 is the same as codes 31256 or 31287 – they are opening up the sinus to help it drain more effectively and to have a look around. This code also includes removal of tissue such as inflamed mucosa or polyps “when performed” but unlike codes 31267 and 31288, there is no requirement that the surgeon has to remove tissue from the frontal sinus to receive credit for this code.
The codes we have talked about to point are for work performed in individual sinuses. However, it’s very common to see two or more sinuses that are operated on during the same surgery. So what happens when work is performed in more than one sinus on the same side (e.g., all procedures on the left) during the same case?
While some of the codes we just talked about can be billed by themselves or in combination with each other, there are other codes that may not be billed together for work on the same side during the same surgery based on CPT and NCCI guidelines. Instead of stringing together multiple individual sinus endoscopy codes, you have to report a single combination code that describes the work of two procedures together when performed on the same side. These combination codes were introduced to CPT in 2018 and have generated a lot of questions for coders and physicians alike. Let’s take a look at these new codes:
- CPT 31253: Nasal/sinus endoscopy, surgical, with ethmoidectomy; total (anterior and posterior), including frontal sinus exploration, with removal of tissue from frontal sinus, when performed
Coding tip: This code includes the work of CPT 31255 (total ethmoidectomy) and CPT 31276 (frontal sinus exploration) when performed on the same side
- CPT 31257: Nasal/sinus endoscopy, surgical, with ethmoidectomy; total (anterior and posterior), including sphenoidotomy
Coding tip: This code includes the work of CPT 31255 (total ethmoidectomy) and CPT 31287 (sphenoidotomy) when performed on the same side
- CPT 31259: Nasal/sinus endoscopy, surgical, with ethmoidectomy; total (anterior and posterior), including sphenoidotomy, with removal of tissue from the sphenoid sinus
- Coding tip: This code includes the work of CPT 31255 (total ethmoidectomy) and CPT 31288 (sphenoidotomy with removal of tissue) when performed on the same side
As you can see, if a total ethmoidectomy is performed in conjunction with surgery on the sphenoid sinus or the frontal sinus on the same side, you must report one of the combination codes above. You cannot report the two individual codes for the sinus work (e.g., 31255 and 31287) together when work occurs on the same side.
Another quandary these new codes have created surrounds how to code a surgery where the physician performs a total ethmoidectomy with work in the sphenoid and frontal sinuses on the same side. Work on all three sinuses occurs in a very common ENT procedure known as a FESS (functional endoscopic sinus surgery). The questions arise because you cannot report more than one of the combination codes above for work on the same side since all codes include the work of a total ethmoidectomy. To report more than one of the combination codes for the same side would cause you to report the total ethmoidectomy for the same ethmoid sinus twice which would be “double dipping.” So the question becomes how do you choose which combination code to use and which sinus work should be individually reported?
Since there are multiple versions of “correct coding” for the same procedure, act in the best interest of the physician from a coding/billing perspective and use the combination code for the total ethmoidectomy and the work in the sphenoid sinus (31257 or 31259) and the individual sinus code for the frontal sinus (31276) when all three sinuses are addressed on the same side during the same surgery. When these codes were first introduced, I performed an analysis of RVUs and allowable amounts for each of the three codes – 31253, 31257, and 31259 – for my top payers for my physicians/clients. I found that pairing the combination code for the total ethmoidectomy/sphenoid sinus work was the most advantageous way to report a FESS procedure. In addition to my analysis, the AMA also issued a CPT Assist article in April 2018 where someone posed this same question of how to code work a total ethmoidectomy, sphenoidotomy, and frontal sinus exploration on the same side. The AMA responded that they should use 31257 for the total ethmoidectomy and sphenoidotomy and CPT 31276 for the work on the frontal sinus. So not only is this the most advantageous way to code this procedure from a revenue perspective, but we also have the backing of an authoritative source (the AMA) in coding in this manner, which is a win-win for coders and physicians.
As you may have noticed, the combination codes we just discussed include the work of a total ethmoidectomy. If a partial ethmoidectomy is performed in conjunction with work in the sphenoid sinus and/or frontal sinus, it is appropriate to code the individual sinus codes (31254, 31287 or 31288, and 31276) since the definition of the combination codes (which again all include a total ethmoidectomy) has not been met. In addition, work in the maxillary sinus is not included in any of these new combination codes so 31256 or 31267 may be reported in combination with 31253, 31257, or 31259 without issue.
Now that we’ve looked at the codes and their overall definitions, let’s take a look at a couple of examples to put this all together.
Example #1: A patient presents with chronic sinusitis in the maxillary, ethmoid, and sphenoid sinuses. She has failed pharmaceutical management and presents for surgical intervention.
Attention then was directed toward the right side. Lidocaine 1% with 1:100,000 epinephrine was injected in the region of the anterior portion of the left middle turbinate and uncinate process. The endoscope was inserted. The uncinate process was removed systematically superiorly to inferiorly with back-biting forceps. Next, the maxillary antrostomy was identified and expanded with the back-biting forceps and showed polypoid accumulation in the mucosa within the sinus. Forceps and a shaver were used to remove polyps.
The anterior and posterior ethmoid air cells were entered primarily and removed with a shaver and forceps.
Finally, the sphenoid sinus was entered using back-biting forceps. Inspection of the sinus revealed purulent material which was suctioned out, but no significant mucosal or polypoid disease.
The endoscope was withdrawn, and the patient was stable in recovery.
Answer Example #1: The bolded portions of the note above are clues to selecting the correct CPT code. We first see that this procedure occurs on the right. This is important because we have “pairs” of sinuses on the left and the right, so when you are coding sinus endoscopy procedures, you can either code them with modifier 50 for bilateral procedures that occur on both sides, or modifiers RT/LT for procedures that occur on one side. Next, we see that the endoscope is inserted, confirming our approach is endoscopic. Then, the first sinus entered is the maxillary sinus. We see the maxillary antrostomy being made and then “forceps and a shaver used to remove polyps.” So we have an opening into the maxillary sinus with removal of diseased tissue, CPT 31267. Next, the physician enters the ethmoid sinus and removes both the anterior and posterior air cells. This is a total ethmoidectomy. This work by itself would be reported with CPT 31255, but before we settle on that code, we need to keep going and see if any work occurs in the sphenoid or frontal sinuses and should be combined with the total ethmoidectomy in our coding. After completing the total ethmoidectomy, the physician enters the sphenoid sinus using back-biting forceps. This is our sphenoidotomy. He then looks around the sinus and suctions the sinus out. Remember suctioning of a sinus cavity alone does not meet the definition of removal of diseased tissue so we would code for the sphenoidotomy only. A sphenoidotomy by itself is CPT 31287, but since we have a total ethmoidectomy and a sphenoidotomy, both performed on the same side (the right), we will code CPT 31257 instead of 31255 and 31287 individually.
Based on the explanation above, the final coding in this case is CPT 31257.RT and 31267.RT.
Example #2: A patient presents with chronic pansinusitis. She has failed pharmaceutical management and presents for surgical intervention.
Attention then was directed toward the left side. After administering adequate anesthesia, the endoscope was inserted. The uncinate process was removed systematically superiorly to inferiorly with back-biting forceps. Next, the maxillary antrostomy was identified and expanded with the back-biting forceps.
The anterior and posterior ethmoid air cells were entered primarily and removed with a shaver and forceps.
The sphenoid sinus was entered using back-biting forceps. Inspection of the sinus revealed copious polypoid tissue. All polyps were excised using forceps.
Finally, the frontal sinus ostium was identified and enlarged with back-biting forceps. Afterwards inspection of the frontal sinus commenced and purulent material was suctioned until the sinus was clear. This concluded the surgery on the left.
The endoscope was withdrawn, and the patient was stable in recovery.
Answer Example #2: The bolded portions of the note above are clues to selecting the correct CPT code. We first see that the patient has pansinusitis (sinusitis affecting all four sinuses). While this detail is for diagnosis coding, it can also prompt us that the physician may very well perform surgeries in all four sinuses to treat this patient’s extensive disease. Next we see this procedure occurs on the left. Then, we see that the endoscope is inserted, confirming our approach is endoscopic. The first sinus entered is the maxillary sinus. We see the maxillary antrostomy (opening into the maxillary sinus) being made. In this case, no diseased tissue is removed so the code for the maxillary sinus will be CPT 31256. Next, the physician enters the ethmoid sinus and removes both the anterior and posterior air cells. This is a total ethmoidectomy. Again this work by itself would be reported with CPT 31255, but before we settle on that code, we need to keep going and see if any work occurs in the sphenoid or frontal sinuses and should be combined with the total ethmoidectomy in our coding. After completing the total ethmoidectomy, the physician enters the sphenoid sinus using back-biting forceps. This is our sphenoidotomy. He then looks around the sinus and removes polyps using forceps. So we have removal of diseased tissue in the sphenoid sinus. A sphenoidotomy with removal of diseased tissue supports CPT 31288, but since we have a total ethmoidectomy on the same side (the left), let’s hold off on final coding for now until we finish determining everything that happened on the left side. Finally, we see the frontal sinus ostium (opening) being enlarged with forceps. This is a sinusotomy in the frontal sinus. This documentation supports CPT 31276.
So to recap, we have a maxillary antrostomy, a total ethmoidectomy, a sphenoidotomy with removal of diseased tissue, and a frontal sinusotomy with exploration. Since the physician performed a total ethmoidectomy with procedures in both the sphenoid and frontal sinuses, we will code the combination code for the total ethmoidectomy with the work in the sphenoid sinus and then code the frontal and maxillary sinus procedures separately. As we discussed earlier, this is the most advantageous way to report the surgery from a revenue perspective, and the AMA has issued guidance aligning with this method of coding.
So our final codes will be CPT 31259.LT (total ethmoidectomy and sphenoidotomy with removal of diseased tissue); CPT 31276.LT (frontal sinusotomy with exploration); and CPT 31256.LT (maxillary antrostomy).
I hope these guidelines and examples help you to navigate the new sinus endoscopy codes with ease. If you have a specific question or example not addressed in the article that you would like to present, please use the comment field below, and I will provide a response for you and other coders out there with the same question.
