How to do billing for Functional Endoscopic Sinus Surgery (FESS)?

Functional endoscopic sinus surgery (FESS) is a set of minimally invasive surgical techniques which allow direct visual examination and opening of the sinuses for the treatment of chronic rhinosinusitis which has not responded to medical treatment. The use of FESS allows for a much less invasive and traumatic procedure, resulting in shorter surgery and healing times, less postoperative discomfort, and fewer surgical complications. Rhinosinusitis, also referred to as sinusitis, is inflammation of the mucosal membrane lining the nasal cavities and the paranasal sinuses. Rhinosinusitis lasting more than 12 weeks is classified as chronic rhinosinusitis (CRS).

The goals of treating CRS are to eliminate underlying causes, reduce sinus inflammation, and drain nasal passages. Medical therapy is the first-line treatment for CRS. Treatments recommended may include nasal saline sprays, nasal lavage, antibiotic therapy, nasal corticosteroids, oral or injected corticosteroids, decongestants, over-the-counter pain relievers, leukotriene modifiers, and antihistamines. Patients who do not respond to medical therapy are candidates for sinus surgery.

Functional Endoscopic Sinus Surgery (FESS) is proven and medically necessary when one or more of the following conditions are present:

Codes Applicable

The following list(s) of procedure and/or diagnosis codes is provided for reference purposes only and may not be all inclusive. Listing of a code in this policy does not imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Other Policies and Coverage Determination Guidelines may apply.

Documentation Requirements

Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The documentation requirements outlined below are used to assess whether the member meets the clinical criteria for coverage but do not guarantee coverage of the service requested.

Medical notes documenting one or more of the following:

    ·         Chronic Rhinosinusitis (CRS) with all of the following:
    

o    Persistence of symptoms despite administration of full courses of all of the following treatments:

      §  Antibiotic therapy, if bacterial infection is suspected;

§  Nasal lavage; and

§  Intranasal corticosteroids       

o    Recent CT scan results confirming one or more of the following:

§  Mucosal thickening

§  Bony remodeling

§  Bony thickening

§  Obstruction of the ostiomeatal complex

§  Opacified sinus

• Recurrent acute rhino sinusitis with four or more episodes per year with distinct symptom free intervals between episodes and all of the following:

            o   Sinonasal symptoms; and

o   Recent CT scan results confirming evidence of ostial occlusion and/or mucosal thickening in the sinus to be treated             

•  Any of the following:

o   Mucocele

o   Concha bullosa

o   Complications of sinusitis

o   Recent CT scan results confirming tumor

To bill FESS properly, you need good understanding of surgery codes and supporting documentation. Even small mistakes in billing and coding can result in denials that lower your practice revenue. Medical Billers and Coders (MBC) can assist you in remaining on the top of surgery coding and billing. To know more about our services contact us at 888-357-3226 info@medicalbillersandcoders.com