Clinical Indicators: Endoscopic Sinus Surgery, Adult

1. History (one or more required)
   1. Chronic rhinosinusitis without nasal polyps (CRSsNP) with persistent symptoms and objective evidence of disease by endoscopic and/or CT imaging that is refractory to optimal medical treatment
   2. Chronic rhinosinusitis with nasal polyps (CRSwNP) with persistent symptoms and objective evidence of disease by endoscopic and/or CT imaging that is refractory to medical treatment
   3. Allergic fungal rhinosinusitis
   4. Unilateral paranasal sinus opacification, symptomatic or asymptomatic, consistent with CRSsNP, CRSwNP, fungus ball, benign neoplasm (i.e, inverted papilloma), etc.
   5. Complications of sinusitis, including extension to adjacent structures (i.e. orbit, skull base)
   6. Sinonasal polyposis with nasal airway obstruction or suboptimal asthma control
   7. Mucocele
   8. Recurrent acute rhinosinusitis (RARS)
2. Physical Examination
   1. Complete anterior and posterior nasal examination (rhinoscopy after mucosal decongestion)
   2. Examination of nasopharynx (if possible)
   3. Nasal endoscopy
   4. Dental, neurologic, ophthalmologic, and/or pulmonary evaluation may be required in cases of extrasinus involvement
3. Tests
   Note: Imaging studies should be generally obtained after optimal medical therapy. Based on clinical situation (i.e. concern for extrasinus complications or neoplasm), early or emergent imaging may be required to confirm a diagnosis.
   1. Coronal CT scan (minimum 3 mm slice thickness, bone algorithm) is the preferred imaging study
   2. Navigation sinus CT in those cases for which surgical navigation is planned
   3. Sinus MRI with/without contrast for cases with skull base and orbital erosion (on CT imaging), possible neoplasm, AFRS and/or mucocele with orbit and skull base erosion.
   4. Endoscopically directed cultures in select cases
   5. Allergy testing (if symptoms are consistent with allergic rhinitis and non- or under-responsive to pharmacotherapy, eg, antihistamines, intranasal corticosteroids, etc.)
   6. Peripheral eosinophil count, total IgE level, or other laboratory studies may be required at the discretion of the physician.
   7. Immunodeficiency evaluation at the discretion of the physician.
4. Optimal Medical Therapy:
   
   1. Oral antibiotics of 2-4 weeks duration for patients with chronic bacterial sinusitis (culture-directed if possible at the discretion of the physician)
   2. Oral antibiotics with multiple 1-3 week courses for patients with recurrent acute bacterial sinusitis
   3. Systemic and/or topical steroids (at the discretion of the physician)
   4. Saline irrigations (optional)
   5. Topical and/or systemic decongestants (optional, if not contraindicated)
   6. Treatment of concomitant allergic rhinitis, including avoidance measures, pharmacotherapy, and/or immunotherapy (at the discretion of the physician)

Post-Operative Observations

1. Monitor for excessive bleeding; if present, notify surgeon
2. Monitor for excessive headache/pain; if present, notify surgeon
3. Monitor for blurry vision, double vision, eye swelling, etc.; if present, notify surgeon.
4. Monitor for mental status changes; if present, notify surgeon

Postoperative care:

1. Endoscopy for debridement and assessment as clinically warranted – see “Coding Clarification: Post-Endoscopic Sinus Surgery Debridements,” CPT Assistant, Dec. 2011. Vol. 21 Issue 12
2. Monitor for CSF leak and vision changes
3. Endoscopic-guided cultures for exacerbations
4. Additional medical therapy, including but not limited to topical nasal steroids, saline irrigations, and topical antibiotics and/or steroids
5. Coordination of care with other physicians, including PCP, allergist and pulmonologist as warranted

Assess for the following:

1. Improvement in symptoms ascribed to CRS
2. Status of paranasal sinus mucosa
3. Assess of complications, including CSF leak
4. Status of concomitant asthma

Associated ICD-9 Diagnostic Codes (Representative, but not all-inclusive, codes):

• 376.01 Orbital cellulitis, abscess
• 461.0 Acute maxillary sinusitis
• 461.1 Acute frontal sinusitis
• 461.2 Acute ethmoidal sinusitis
• 461.3 Acute sphenoidal sinusitis
• 461.8 Other acute sinusitis, Acute pansinusitis
• 471.0 Polyp of nasal cavity
• 471.1 Polypoid sinus degeneration
• 471.8 Nasal sinus polyp NEC
• 472.0 Chronic rhinitis
• 473.0 Chronic maxillary sinusitis
• 473.1 Chronic frontal sinusitis
• 473.2 Chronic ethmoidal sinusitis
• 473.3 Chronic spheroidal sinusitis
• 473.8 Chronic sinusitis NEC; pansinusitis
• 477.0 Allergic rhinitis, due to pollen
• 477.1 Allergic rhinitis, due to food
• 477.2 Allergic rhinitis, due to animal (cat,dog) hair and dander
• 477.8 Allergic rhinitis, due to other allergen
• 477.9 Allergic rhinitis, cause unspecified
• 478.19 Cyst or Mucocoele of sinus
• 493.0x Extrinsic Asthma
• 493.1x Intrinsic Asthma
• 493.90 Asthma
• 493.92 Asthma exacerbation

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

• H05.011 Cellulitis of right orbit
• H05.012 Cellulitis of left orbit
• H05.013 Cellulitis of bilateral orbit
• H05.019 Cellulitis of unspecified orbit
• J01.00 Acute maxillary sinusitis, unspecified
• J01.01 Acute recurrent maxillary sinusitis
• J01.10 Acute frontal sinusitis, unspecified
• J01.11 Acute recurrent frontal sinusitis
• J01.20 Acute ethmoidal sinusitis, unspecified
• J01.21 Acute recurrent ethmoidal sinusitis
• J01.30 Acute sphenoidal sinusitis, unspecified
• J01.31 Acute recurrent sphenoidal sinusitis
• J01.40 Acute pansinusitis, unspecified
• J01.41 Acute recurrent pansinusitis
• J01.80 Other acute sinusitis
• J01.81 Other recurrent acute sinusitis
• J33.0 Polyp of nasal cavity
• 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
• J30.1 Allergic rhinitis due to pollen
• J30.5 Allergic rhinitis due to food
• J30.81 Allergic rhinitis due to animal (cat)(dog) hair and dander
• J30.9 Other Allergic rhinitis
• J34.1 Cyst and mucocele of nose and nasal sinus
• J45.901 Unspecified asthma, with (acute) exacerbation
• J45.902 Unspecified asthma, with status asthmaticus
• J45.909 Unspecified asthma, uncomplicated
• J45.20 Mild intermittent asthma, uncomplicated
• J45.21 Mild intermittent asthma with (acute) exacerbation
• J45.22 Mild intermittent asthma with status asthmaticus
• J45.30 Mild persistent asthma, uncomplicated
• J45.31 Mild persistent asthma with (acute) exacerbation
• J45.32 Mild persistent asthma with status asthmaticus
• J45.40 Moderate persistent asthma, uncomplicated
• J45.41 Moderate persistent asthma with (acute) exacerbation
• J45.42 Moderate persistent asthma with status asthmaticus
• J45.50 Severe persistent asthma, uncomplicated
• J45.51 Severe persistent asthma with (acute) exacerbation
• J45.52 Severe persistent asthma with status asthmaticus

Patient Information

Endoscopic sinus surgery is performed through the nasal openings and is recommended only after it has been determined that medical management has been, or will be, unsuccessful. Surgery, medical management, and failure to intervene all have risks, including the possibility of postoperative bleeding, eye complications (visual impairment), intracranial injury (brain damage or infection), leakage of cerebrospinal fluid, persistent or recurrent nasal obstruction due to failure to fully control polyps, and recurrent nasal or sinus infections. The risk of surgery should generally be less than that of un- or under treated sinus disease.

Radiographs (xrays) and endoscopic findings considered in conjunction with the patients’ clinical status – following medical evaluation and therapy will help the surgeon develop the most appropriate, tailored treatment plan.

Definitions

1. Acute rhinosinusitis (ARS): ARS is a clinical condition characterized by inflammation of the
   mucosa of the nose and paranasal sinuses with associated sudden onset of symptoms of purulent
   nasal drainage accompanied by nasal obstruction, facial pain/pressure/fullness, or both of up to 4
   weeks duration.
2. Recurrent acute rhinosinusitis (RARS): RARS is characterized by 4 or more recurrent episodes of ARS with complete clearing of symptoms between episodes over a one year period.
3. Chronic rhinosinusitis (CRS): CRS is a clinical disorder characterized by inflammation of the mucosa of the nose and paranasal sinuses with associated signs and symptoms of 12 week consecutive duration. CRS is characterized by 2 or more symptoms, one of which is nasal blockage/obstruction/congestion or nasal discharge (anterior/posterior nasal drip), with or without facial pain/pressure and reduction or loss of smell with endoscopic evidence of mucopurulence, edema, and/or polyps and/or CT presence of mucosal thickening or air-fluid levels in the sinuses.
4. Chronic rhinosinusitis with polyposis: CRS with polyposis represents a subgroup of CRS patients with endoscopic evidence of unilateral or bilateral polyps in the middle meatus.
5. Functional endoscopic sinus surgery (FESS): FESS is a minimally invasive, mucosal sparing surgical technique utilized to treat medically refractory CRS with or without polyps or recurrent acute rhinosinusitis. Rigid endoscopes are employed to visualize the surgical field to achieve one or more of the following goals: (1) to open the paranasal sinuses to facilitate ventilation and drainage from the paranasal sinuses; (2) to remove polyps and/or osteitic bony fragments to reduce the inflammatory load; (3) to enlarge the sinus ostia to achieve optimal instillation of topical therapies; and (4) to obtain bacterial or fungal cultures and tissue for histopathology.

Important Disclaimer Notice (Updated 8/7/14)

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. Clinical indicators are not intended to and should not be treated as legal, medical, or business advice.

CPT five-digit codes, nomenclature and other data are copyright 2014 American 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.

Updated January 2015

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