Clinical Indicators: Septoplasty
Clinical IndicatorHistory (one or more required) Nasal airway obstruction (unilateral or bilateral) causing any of the following: mouth breathing, snoring, nasal congestion, …
Clinical Indicators: Rhinoplasty
Clinical IndicatorHistory (one or more required) Obstructed breathing (functional). Unsatisfactory appearance. Nasal injury (trauma) causing unsatisfactory breathing and/or…
Clinical Indicators: Laryngectomy
Clinical IndicatorHistory (all required) Symptoms--describe patient complaints of voice change, difficulty swallowing and/or breathing, hemoptysis, unexplained weight loss, t…
Clinical Indicators: Laryngoscopy/Nasopharyngoscopy
Clinical Indicator*If appropriate, a "-25" modifier must be added to the Evaluation and Management (E & M) code if this procedure is performed on the same date. History (on…
Clinical Indicators: Inferior Turbinate Surgery
Clinical IndicatorHistory (required) Chronic nasal obstruction due in part to inferior turbinate hypertrophy. Failure of directed medical management with continued nasal sy…
Clinical Indicators: Ethmoidectomy
Clinical IndicatorHistory (one or more required) Failure of optimal medical management (describe) for acute orchronic ethmoid sinusitis. Multiple or recurrent nasal polyps c…
Clinical Indicators: Endoscopic Sinus Surgery, Pediatric
Clinical IndicatorHistory (one or more required)(The history must include specific symptoms and findings obtained by the otolaryngologist. A historical diagnosis labeled "sinu…
Clinical Indicators: Tracheostomy
Clinical Indicator1. History (One or more required)a. Upper airway obstruction with any of the following: stridor, air hunger, retractions, obstructive sleep apnea bi…
Clinical Indicators: Endoscopic Sinus Surgery, Adult
Clinical IndicatorHistory (one or more required) Chronic rhinosinusitis without nasal polyps (CRSsNP) with persistent symptoms and objective evidence of disease by endoscopic…
Clinical Indicators: Canalith Repositioning Procedures (CRPs)
Clinical Indicator(Otolith Repositioning; Epley Maneuver; Semont Maneuver, Lateral canal repositioning maneuvers)Indications1. History (one or more required) Description of par…
Clinical Indicators: Endoscopic Debridement
Clinical IndicatorHistory (one or more required after failure of mechanical therapy) Postoperative care of endoscopic sinus surgery Postoperative hemorrhage Postoperative e…
Clinical Indicators: Diagnostic Nasal Endoscopy
Clinical Indicator*Note: Separate Procedure by CPT definition means the code should not be reported with other procedures of which it is a part; in this case, therapeutic nasal/…
Clinical Indicators: Nasal Fracture (with or without septal fracture)
Clinical IndicatorHistory (required) Recent nasal trauma with deformity Physical Examination (required) Evidence of nasal septal fracture (with or without concomitant nasal…
Clinical Indicators: Mandibular Fracture
Clinical IndicatorHistory Trauma Malocclusion perceived by patient Trismus Airway patency concerns Physical Examination Evidence of fracture Palpate or visualize deform…
Clinical Indicators: Le Fort Fracture
Clinical IndicatorHistory Trauma, indicate mechanism of injury Clear rhinorrhea Visual problems Malocclusion/dental status Trismus Facial numbness Difficulty with sense…
Clinical Indicators: Neck Dissection
Clinical Indicator*Note: Radical neck dissection performed in conjunction with removal of a primary malignancy is coded with the primary; in some instances a single CPT codes de…
Clinical Indicators: Thyroidectomy
Clinical IndicatorHistory (one or more required) Thyroid mass Family history of thyroid disease History and/or symptoms of hyper or hypothyroidism History of radiation to …
Clinical Indicators: Palatopharyngoplasty for Obstructive Sleep Apnea
Clinical IndicatorHistory (One or more required) Chronic snoring Restless or interrupted sleep Excessive daytime sleepiness Witnessed apneas or gasping during sleep Prese…
