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Clinical Indicators: Endoscopic Debridement

Clinical Indicators: Endoscopic Debridement
Approach ProcedureCPTRBRVS Global Days
Nasal/sinus endoscopy, surgical; with biopsy, polypectomy, or
debridement (separate procedure)
  1. History (one or more required after failure of mechanical therapy)
    1. Postoperative care of endoscopic sinus surgery
    2. Postoperative hemorrhage
    3. Postoperative exudate or discharge
    4. Complications of endoscopic sinus/skull base surgery
    5. Fungal sinusitis
  2. Physical Examination
    1. Complete anterior and posterior nasal examination (rhinoscopy after mucosal decongestion (one or more required)
      1. Significant (early or late) scar formation, particularly in the region of the middle meatus or the frontal recess
      2. Significant (early or late) sinus ostial stenosis or obstruction
      3. Significant granulation, persistent crusting, mucinous secretions, purulent debris, or polypoid tissue, unresponsive to medical therapy
      4. Bleeding or cerebrospinal fluid drainage

Postoperative Observations (Following Primary Surgery)

  1. Bleeding, eyelid ecchymosis
  2. Pain – severe headache
  3. CSF leak

Outcome Review

  1. One Week
    1. Healing – Is surgical site healing satisfactorily? Did patient require treatment for bleeding or infection? Is there persistent crusting, mucopurulent secretions, or polypoid inflammation? Is there evidence of synechiae formation or ostial narrowing/obstruction?
    2. Are there any indications for CSF rhinorrhea?

Associated ICD-10-CM Codes (Representative, but not all-inclusive codes)

  • C75.1 Malignant neoplasm of pituitary gland
  • C75.2 Malignant neoplasm of craniopharyngeal duct
  • D14.0 Benign neoplasm of middle ear, nasal cavity and accessory sinuses
  • D02.3 Carcinoma in situ of other parts of respiratory system
  • D38.5 Neoplasm of uncertain behavior of other respiratory organs
  • D38.6 Neoplasm of uncertain behavior of respiratory organ, unspecified
  • G96.0 Cerebrospinal fluid leak
  • H04.201 Unspecified epiphora, right lacrimal gland
  • H04.202 Unspecified epiphora, left lacrimal gland
  • H04.203 Unspecified epiphora, bilateral lacrimal glands
  • H05.011 Cellulitis of right orbit
  • H05.012 Cellulitis of left orbit
  • H05.013 Cellulitis of bilateral orbit
  • J01.30 Acute sphenoidal sinusitis, unspecified
  • J01.31 Acute recurrent sphenoidal sinusitis
  • J01.20 Acute ethmoidal sinusitis, unspecified
  • J01.21 Acute recurrent ethmoidal sinusitis
  • J01.00 Acute maxillary sinusitis, unspecified
  • J01.01 Acute recurrent maxillary sinusitis
  • J33.1 Polypoid sinus degeneration
  • J33.8 Other polyp of sinus
  • J32.0 Chronic maxillary sinusitis
  • J32.1 Chronic frontal sinusitis
  • J32.2 Chronic ethmoidal sinusitis
  • J32.3 Chronic sphenoidal sinusitis
  • J32.4 Chronic pansinusitis
  • J32.8 Other chronic sinusitis
  • J34.81 Nasal mucositis (ulcerative)
  • E05.00 Thyrotoxicosis with diffuse goiter without thyrotoxic crisis or storm
  • E05.01 Thyrotoxicosis with diffuse goiter with thyrotoxic crisis or storm
  • H05.89 Other disorders of orbit
  • H05.239 Hemorrhage of unspecified orbit
  • H05.231 Hemorrhage of right orbit
  • H05.232 Hemorrhage of left orbit
  • H05.233 Hemorrhage of bilateral orbit
  • H05.229 Edema of unspecified orbit
  • H05.221 Edema of right orbit
  • H05.222 Edema of left orbit
  • H05.223 Edema of bilateral orbit
    • S05.10X- Contusion of eyeball and orbital tissues, unspecified eye
    • S05.11X- Contusion of eyeball and orbital tissues, right eye
    • S05.12X- Contusion of eyeball and orbital tissues, left eye

The appropriate 7th character is to be added to each code from category S05
A – initial encounter
D – subsequent encounter
S – sequel

Additional Information

Assistant Surgeon — N

Patient Information

Following endoscopic sinus surgery procedures, your surgeon will monitor the healing to provide the greatest assurance that the sinuses will remain healthy. This evaluation includes examination of the interior of the nose and the region where sinus surgery was performed. Your surgeon may recommend examining these areas of the nose with a rigid or flexible scope one or more times after surgery. At times, a localized cleaning (debridement) of the area may also be performed. The decision regarding these procedures depends on your surgeon’s assessment of healing and your health. Any anesthesia, whether topical or general, is patient dependent.

Important Disclaimer Notice

Clinical indicators for otolaryngology serve as a checklist for practitioners and a quality care review tool for clinical departments. The American Academy of Otolaryngology—Head and Neck Surgery, Inc. and Foundation (AAO-HNS/F) Clinical Indicators are intended as suggestions, not rules, and should be modified by users when deemed medically necessary. In no sense do they represent a standard of care. The applicability of an indicator 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 indicators will not ensure successful treatment in every situation. The AAO-HNS/F emphasizes that these clinical indicators 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. The AAO-HNS/F is not responsible for treatment decisions or care provided by individual physicians.

CPT five-digit codes, nomenclature and other data are copyright 2014American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein.

© 2014 American Academy of Otolaryngology-Head and Neck Surgery.

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