Debridement of the Sinus Cavity after ESS
Debridement of the sinus cavity is a procedure commonly performed following endoscopic sinus surgery (ESS). It involves transnasal insertion of the endoscope for visualization and parallel insertion of various instruments for the purpose of removal of postsurgical crusting, residua of dissolvable spacers, coagulum, early synechiae, or devitalized bone or mucosa. It may also be utilized to remove crusts or debris in patients with longstanding chronic sinusitis with persistent sinonasal inflammation who have undergone sinus surgery in the past. It is performed under local or general anesthesia in a suitably equipped office or operating room, depending on the clinical circumstances of the case.
It is the position of the Academy that postoperative debridement aids healing and optimizes the ability to achieve open, functional sinus cavities. This also facilitates optimal instillation of topical therapies and saline irrigations, long-term disease surveillance, and endoscopically-derived cultures.
Similar improvement in control of inflammation and secondary infection is obtained by debridement in other subtypes of chronic sinusitis patients; particularly in recurrent/persistent bacterial infections and/or fungal sinusitis. Debridement may also be required in patients with chronic crusting in the setting of previous endoscopic tumor surgery and/or paranasal sinus radiation.
- The frequency with which the above mentioned procedure should be performed is a clinical judgement best made by the surgeon and determined on a case-by-case basis, with the patients clinical interests as the criteria of need. Setting an arbitrary limit on the number of debridements does not account for variability between patients in the healing process or severity of disease and can significantly jeopardize the quality of care which patients receive and negatively affect the overall outcome of ESS.
- The Medicare fee schedule, the source for the concept of global periods, clearly assigns zero follow-up days to the 31237 code and most ESS procedures (several have a 10 day period: 31239 and 31290-31294). The reason for this assignment is that in the initial formulation of the relative value units for ESS, need for debridement of the sinus cavity was noted to vary greatly depending on the individual surgical case. ESS relative value units were developed with this exclusion of debridements factored into their overall weight: ESS code values do not include the work, risk, judgement, and skill necessary for this separate procedure.
Medicare work values assigned to the various codes for ESS took into account all of these factors. Haphazardly assigning lower work-valued codes in the place of 31237 as well as tampering with the Medicare global periods assigned, leads to the skewing of several of the key elements which were arrived at to produce fairness and equitable payments for the work done. This results in incorrectly lowered payments, inconsistent with the level, volume, and intensity of the work performed.
- Insurance companies which profess to use Medicare approaches to reimbursements should use all of the critical elements of those formulations to be consistent with the work values and payment rules inherent in the Medicare concepts mentioned.
- Sinus surgery is unilateral in nature as are debridements done thereafter. Payments for these procedures should be also. Adopted 10-18-12 Guidelines are not a substitute for the experience and judgment of a physician and are developed to enhance the physicians' ability to practice evidence-based medicine.
Important Disclaimer Notice (updated 7/31/14)
Position statements are approved by the American Academy of Otolaryngology—Head and Neck Surgery, Inc. or Foundation (AAO-HNS/F) Boards of Directors and are typically generated from AAO-HNS/F committees. Once approved by the Academy or Foundation Board of Directors, they become official position statements and are added to the existing position statement library. In no sense do they represent a standard of care. The applicability of position statements, as guidance for a procedure, must be determined by the responsible physician in light of all the circumstances presented by the individual patient. Adherence to these clinical position statements will not ensure successful treatment in every situation. As with all AAO-HNS/F guidance, this position statement should not be deemed inclusive of all proper treatment decisions or methods of care, nor exclusive of other treatment decisions or methods of care reasonably directed to obtaining the same results. Position statements are not intended to and should not be treated as legal, medical, or business advice.