Most sinus surgeries performed are called Functional Endoscopic Sinus Surgery (FESS), which are procedures performed to open up sinus cavities to promote airflow and drainage. Properly coding these procedures requires understanding of sinus anatomy and being familiar with the parenthetical notes in this section of the CPT book. Here are five tips to get you started in correct code selection:
- Identify the side of the nose where the procedure is performed. FESS CPT codes are unilateral procedures, but can be reported bilaterally, when performed.
- Determine which sinuses the scope entered. There are four sinuses on each side of the nose:
- Was tissue removed from the sinus, or was it simply entered/opened? For example, if the maxillary sinus was opened, the code would be 31256, but if it was opened, and had tissue removed, the code would be 31267.
- Look for any dilation (e.g., balloon dilation). Any opening or tissue removal is included in the dilation when performed on the same sinus.
- Once your initial codes are determined, carefully review the parenthetical instructions following each of the codes, as there are many “do not report with” guidelines to help you with final code selection. Always keep in mind the parenthetical guidelines only apply to procedures performed on the ipsilateral (same) side.
Coding for sinus surgery can be overwhelming at first, especially because these procedures can occur in multiple different combinations, depending on the patient’s condition. However, taking these five tips and breaking down the operative report one sinus at a time, will help get you started.
Register for our on-demand webinar Sinus Surgery - CPT Coding for the Nose to take a deeper dive into CPT coding for sinuses and review multiple coding scenarios!
Deanna Upston, CPMA, CPC, COSC