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A surgical nasal/sinus endoscopy with sphenoidotomy is a specialized procedure that involves the use of an endoscope to visualize and access the sphenoid sinus, which is located deep within the skull behind the nasal cavity. This procedure is typically performed to diagnose and treat various conditions affecting the nasal passages and sinuses, such as chronic sinusitis, polyps, or other abnormalities. Prior to the procedure, a topical nasal decongestant and a local anesthetic with a vasoconstrictor may be applied to minimize discomfort and reduce bleeding during the surgery. The endoscope, a thin, flexible tube equipped with a camera and light source, is inserted through the nostril to provide a clear view of the nasal cavity and the paranasal sinuses. The surgeon can then inspect these areas for any signs of disease or abnormalities. The sphenoid sinus can be accessed through different approaches, including a medial or lateral approach to the middle turbinate, or through the removal of the middle turbinate or a transseptal approach. Once the sphenoid sinus is accessed, the surgeon can perform a sphenoidotomy, which involves creating an opening in the sinus to allow for drainage and the removal of any diseased tissue. This procedure may also include the collection of tissue samples for culture and sensitivity testing, as well as irrigation of the sinus to ensure proper cleansing and healing.
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The procedure is indicated for various conditions affecting the sphenoid sinus and surrounding structures. These may include:
The surgical procedure involves several key steps to ensure effective access and treatment of the sphenoid sinus. These steps include:
After the procedure, patients may experience some discomfort, which can be managed with prescribed pain relief medications. It is important to monitor for any signs of complications, such as excessive bleeding or infection. Patients are typically advised to avoid strenuous activities and follow specific post-operative care instructions provided by their healthcare provider. Follow-up appointments may be scheduled to assess healing and ensure that the sinus is functioning properly.
| Short Descr | NASAL/SINUS ENDOSCOPY SURG | Medium Descr | NASAL/SINUS ENDOSCOPY W/SPHENOIDOTOMY | Long Descr | Nasal/sinus endoscopy, surgical, with sphenoidotomy; | Status Code | Active Code | Global Days | 000 - Endoscopic or Minor Procedure | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 3 - Special payment adjustment rules for multiple endoscopic procedures apply. | Bilateral Surgery (50) | 1 - 150% payment adjustment for bilateral procedures applies. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 0 - Payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Endoscopic Base Code | 31231 Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure) | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Hospital Part B services paid through a comprehensive APC | ASC Payment Indicator | Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P8I - Endoscopy - other | MUE | 1 | CCS Clinical Classification | 33 - Other OR therapeutic procedures on nose, mouth and pharynx |
| 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 50 | Bilateral procedure: unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code. note: this modifier should not be appended to designated "add-on" codes (see appendix d). | LT | Left side (used to identify procedures performed on the left side of the body) | RT | Right side (used to identify procedures performed on the right side of the body) | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service | 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | CR | Catastrophe/disaster related | GA | Waiver of liability statement issued as required by payer policy, individual case | GC | This service has been performed in part by a resident under the direction of a teaching physician | SG | Ambulatory surgical center (asc) facility service | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure |
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| 2018-01-01 | Changed | AMA guideline added. |
| 2011-01-01 | Changed | Short description changed. |
| 2010-01-01 | Changed | Code description changed. |
| 1994-01-01 | Added | First appearance in code book in 1994. |
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