CPT Coding for Maxillary Sinusotomy with Antrostomy and Tissue Removal
The correct CPT code for a diagnostic maxillary sinusotomy followed by a maxillary antrostomy with tissue removal is 31267.
Understanding the Procedure Components
When coding for sinus procedures, it's essential to identify the specific procedure performed and any additional work that extends beyond the base procedure. In this case:
- The procedure began as a diagnostic maxillary sinusotomy
- During the procedure, diseased tissue was observed
- The provider performed a maxillary antrostomy with tissue removal
- Bleeding was controlled and the patient tolerated the procedure well
CPT Code Analysis
31231 - Nasal Endoscopy, Diagnostic
- This code represents a diagnostic nasal endoscopy only
- Does not include sinus access or tissue removal
- Insufficient to capture the full extent of the procedure performed
31267 - Nasal/Sinus Endoscopy, Surgical with Maxillary Antrostomy
- Includes access to the maxillary sinus
- Includes removal of tissue from the maxillary sinus
- Accurately captures both the antrostomy and tissue removal components
31254 - Nasal/Sinus Endoscopy, Surgical with Ethmoidectomy
- This code is for ethmoid sinus procedures
- No ethmoidectomy was performed in this case
- Not applicable to the described procedure
31256 - Nasal/Sinus Endoscopy, Surgical with Maxillary Antrostomy
- Includes access to the maxillary sinus
- Does not include tissue removal
- Insufficient to capture the full extent of the procedure performed
Coding Rationale
The key distinction in this case is that the procedure involved both an antrostomy (surgical opening into the maxillary sinus) and removal of diseased tissue. When tissue removal is performed during a maxillary antrostomy, CPT code 31267 is the appropriate choice as it encompasses both components of the procedure 1.
The fact that the procedure began as diagnostic but evolved into a therapeutic intervention when diseased tissue was discovered means the final, more comprehensive code (31267) should be reported rather than the diagnostic code (31231) 1.
Common Coding Pitfalls to Avoid
- Underreporting the procedure: Using only 31256 would fail to account for the tissue removal component
- Incorrect anatomical site: Using 31254 would incorrectly indicate an ethmoid procedure rather than maxillary
- Reporting only the diagnostic component: Using 31231 would fail to capture the therapeutic intervention
Clinical Context
Maxillary antrostomy with tissue removal is commonly performed for patients with chronic maxillary sinusitis who have failed medical therapy. The procedure creates access to the maxillary sinus through the middle meatus and allows for removal of diseased tissue, improving sinus drainage and ventilation 1.
The patency of the surgically created ostium is critical for the success of the procedure, with most surgeons creating an opening of 3-4mm that allows for proper drainage while maintaining as much normal anatomy as possible 1.
Remember that accurate CPT coding is crucial not only for appropriate reimbursement but also for compliance with Medicare policies and other third-party payers 2.