A common, minimally-invasive surgical procedure, functional endoscopic sinus surgery (FESS) is a procedure used to remove sinus polyps and other types of abnormalities of the nose that cause significant breathing problems, including sinusitis. Sinusitis occurs due to an inflammation (swelling) of the mucous membranes that line the sinus cavities. It can cause the sinuses to get blocked and filled with fluid. The condition is usually caused by cold or allergies. FESS has become the accepted standard approach and technique when surgical treatment of sinusitis is indicated. Billing and coding for this procedure can be challenging. Outsourcing billing and coding tasks to reputable medical billing companies is a great option physicians can consider to save valuable time and ensure accurate medical coding.

Why Is FESS Performed?

Generally, functional endoscopic sinus surgery (FESS) is recommended for patients suffering from chronic sinusitis that persists despite undergoing aggressive medical treatment (like antibiotics, oral steroids, nasal sprays or other anti-allergy treatments). FESS may also be recommended for patients who suffer from certain other conditions like – enlarged nasal turbinates, deviated septum, nasal polyps and have four or more episodes of acute sinusitis a year. As bacterial infection is one of the important factors that cause chronic sinusitis, initial treatment includes long courses of oral antibiotics. Other medications that reduce inflammation (mostly steroids) and reduce mucus viscosity are also used. When these treatments do not provide meaningful improvement, or the symptoms return after treatment is stopped, then sinus surgery is considered. In certain other cases, FESS may be required for the drainage of mucocele (a blocked sinus that is filled with mucus and slowly expanding). Mucoceles typically produce no symptoms until they are quite large and compressing the eye or brain. Thus, early drainage is required to prevent this complication.

What Does the FESS Procedure Involve?

The decision to proceed with sinus surgery is a complex one that requires careful consideration of several factors. The process begins with an initial evaluation including a detailed physical examination and medical history evaluation. Nasal examination or nasal endoscopy, sinus CT findings and response to previous treatments will also be performed as part of the evaluation. In addition, routine preoperative testing like blood testing, EKG, and CXR will be performed depending upon the overall health condition of the patient. In most cases, patients are administered general anesthesia as part of the surgery.

The surgical procedure begins with the surgeon inserting an endoscope into the nasal cavity through a nostril that relays images of the nasal obstructions back to the surgeon. The surgeon will use small precision instruments to detect any abnormal tissue or polyps that are making it impossible for the sinuses to drain properly. The surgeon will remove or reposition these abnormalities with tiny, precision cutting instruments inserted into the nostril. However, in special cases, the surgeon may choose to insert a spring-like implant called “Propel” into the surgery area. The device keeps the affected area open and releases a measured dose of cortisone to prevent polyps from reforming and reduce scar formation. The device dissolves over the course of a month.

Once the procedure is completed, temporary nasal packing will be placed inside the nose to support the newly opened sinus passages and to absorb excess fluid while the tissues heal. Patients can expect minimal swelling, bleeding and pain for approximately 1-2 weeks, soon after the procedure. In addition, patients may also experience nasal congestion during this same time span. They should not blow their nose for at least two weeks following surgery. As normal sinus drainage becomes reestablished, patients can blow out some thick bloody mucus. Most patients can resume normal activities a week after the procedure. Soon after the completion of the surgery, patients will receive detailed instructions about post-operative care which may include – nasal irrigations and consumption of oral antibiotics and pain medicine. In addition, routine post-operative office visits are necessary. During these visits, the surgical cavity is cleaned and inspected. Early scar tissue may be removed, and the medical treatment strategy will be adjusted on that basis.

Documentation Guidelines for FESS

For reimbursement, the clinical documentation must indicate the medical necessity of FESS. United Healthcare considers Functional Endoscopic Sinus Surgery (FESS) as proven and/or medically necessary for one or more of the following –

  • Patients with chronic rhinosinusitis (defined as rhinosinusitis lasting longer than 12 weeks) with both of the following –
    • Chronic rhinosinusitis of the sinus to be operated on is confirmed on computed tomography (CT) scan by one or more of the following: Mucosal thickening; Bony remodeling; Bony thickening; Obstruction of the ostiomeatal complex, and Opacified sinus.
    • Symptoms persist despite medical therapy with one or more of the following like -nasal lavage; antibiotic therapy, if bacterial infection is suspected, and intranasal corticosteroid
  • Mucocele documented on CT scan
  • Concha bullosa documented on CT scan
  • Complications of sinusitis such as abscess
  • Tumor documented on CT scan (such as polyposis or malignancy)
  • Recurrent acute rhinosinusitis (RARS)

Applicable Medical Codes to Report FESS

Medical billing and coding involve using the relevant CPT codes and the ICD-10 codes on the medical claims submitted to health insurers. A professional medical billing company will provide the services of experienced medical coders who are up to date with the changing coding regulations and guidelines related to the procedure.

CPT Codes

Functional Endoscopic Sinus Surgery (FESS) Codes

  • 31240 – Nasal/sinus endoscopy, surgical; with concha bullosa resection
  • 31253 – Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including frontal sinus exploration, with removal of tissue from frontal sinus, when performed
  • 31254 – Nasal/sinus endoscopy, surgical with ethmoidectomy; partial (anterior)
  • 31255 – Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior)
  • 31256 – Nasal/sinus endoscopy, surgical, with maxillary antrostomy
  • 31257 – Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including sphenoidotomy
  • 31259 – Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including sphenoidotomy, with removal of tissue from the sphenoid sinus
  • 31267 – Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus
  • 31276 – Nasal/sinus endoscopy, surgical with frontal sinus exploration, including removal of tissue from frontal sinus, when performed
  • 31287 – Nasal/sinus endoscopy, surgical, with sphenoidotomy
  • 31288 – Nasal/sinus endoscopy, surgical, with sphenoidotomy; with removal of tissue from the sphenoid sinus

Balloon Sinus Dilation Codes

  • 31295 -Nasal/sinus endoscopy, surgical; with dilation of maxillary sinus ostium (e.g., balloon dilation), transnasal or canine fossa
  • 31296 – Nasal/sinus endoscopy, surgical; with dilation of frontal sinus ostium (e.g., balloon dilation)
  • 31297 – Nasal/sinus endoscopy, surgical; with dilation of sphenoid sinus ostium (e.g., balloon dilation)
  • New/Bundled 31298 -Nasal/sinus endoscopy, surgical; with dilation of frontal and sphenoid sinus ostia (e.g., balloon dilation)

New Sphenopalatine Artery Code

  • 31241 -Nasal/sinus endoscopy, surgical; with ligation of sphenopalatine artery

ICD Codes for Sinusitis

  • J01 Acute sinusitis
  • J01.0 Acute maxillary sinusitis
    • J01.01 Acute recurrent maxillary sinusitis
    • J01.11 Acute recurrent frontal sinusitis
  • J01.2 Acute ethmoidal sinusitis
    • J01.21 Acute recurrent ethmoidal sinusitis
  • J01.3 Acute sphenoidal sinusitis
    • J01.31 Acute recurrent sphenoidal sinusitis
  • J01.4 Acute pansinusitis
    • J01.41 Acute recurrent pansinusitis
  • J01.8 Other acute sinusitis
    • J01.80 Other acute sinusitis
    • J01.81 Other acute recurrent sinusitis
  • J01.9 Acute sinusitis, unspecified
    • J01.90 Acute sinusitis, unspecified
    • J01.91 Acute recurrent sinusitis, unspecified

Otolaryngology medical billing and coding can be quite challenging for otolaryngologists and their physician team. Outsourcing medical billing and coding tasks to a reputable medical billing company is a practical option for physicians to ensure accurate clinical documentation for this procedure. We provide the services of experienced coders who will review medical records carefully to assign the right codes and ensure maximum reimbursement for all otolaryngology procedures performed.