Editor’s note: Dr. Setzen disclosed that he has done work with Gyrus-ACMI, Brain Lab, and Acclarent.
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May 2007MARCO ISLAND, FL-Balloon sinuplasty-still a controversial area for otolaryngologists-appears to be gaining favor, although functional endoscopic balloon remodeling is still in its infancy, said Raymond Weiss, MD, medical director of the Sinus Center of the South in Ocean Springs, MS.
In a panel discussion on sinuplasty at the 2007 combined sections meeting of the Triological Society, Dr. Weiss explained some of the uses of the catheter-balloon procedure. He was joined by Michael Setzen, MD, Clinical Associate Professor in Otolaryngology at the New York University School of Medicine and Chief of the Rhinology Section at North Shore University Hospital in Manhasset, NY, who explained how practitioners can bill for sinuplasty using current procedural terminology (CPT) codes.
Dr. Weiss said that doctors should not look at sinuplasty as a new procedure but rather as a tool or technique that can help perform the common treatments that are often accomplished using endoscopic sinus surgery tools-especially the endoscope.
Functional endoscopic balloon remodeling is a new technique using a new tool to alternately perform a known surgical procedure, Dr. Weiss said. Sinuplasty is a new technique in performing endoscopic sinus surgery-not a new procedure but rather a new tool that further reduces mucosal damage and advances us toward our ultimate goal of improving function with maximal mucosal preservation.
Dr. Weiss noted that in traditional endoscopic sinus surgery the choice for preservation was previously dictated by degree of destruction. The concept of maximum mucosal preservation remained in the forefront of the clinician’s thinking. However, this still is within the realm of tissue removal, he said. The advent of new endoscopic sinus surgery tools have allowed us to begin exploring new levels of tissue preservation that were previously unrealistic-while still improving function.
He said that when patients and doctors are dealing with isolated sinus disease, the choice of treatment is fairly clear for those who have balloon remodeling available. However, the picture is less clear when treating chronic sinusitis and determining how to fit in this new tool when the patient is also going to require the use of traditional destructive techniques, he added.
Sinuplasty Concepts
Dr. Weiss said the basic concepts for performing sinuplasty are:
- To maximize mucosal preservation.
- To give the patient a choice in treatment and a choice that preserves tissue.
- To give the sinus a chance to function by remodeling the existing outflow tract.
- To burn no bridges, by taking a step-by-step minimally invasive approach to treating sinus disease.
In general terms, Dr. Weiss said that the clinician, in performing sinuplasty, first must gain access to the sinus with a soft flexible wire. Then a balloon with specific characteristics is advanced along the guidewire until it is in position. Then, by pressurizing the balloon slowly, the clinician can moving the eggshell-thin bone, which in turn moves the attached mucosa. The technique, Dr. Weiss said, minimizes any destructive component of surgery.
In current practice, he said, doctors can use sinuplasty as a pure procedure with just the balloon technique or it can be used in a hybrid fashion-balloon remodeling along with some surgery, usually ethmoidectomy.
Case Histories Illustrative
He showed case histories illustrating each of the techniques:
An example of pure sinuplasty is a 35-year-old woman Realtor, who five months previously had undergone right molar extraction with resultant oroantral fistula. She was treated with more than 60 days of antibiotics, three months of nasal steroid spray, and four failed attempts to surgically close the fistula. She underwent sinuplasty with isolated remodeling of the right maxillary outflow tract. The last follow-up was 12 weeks after the operation and she was doing well. The fistula closed spontaneously.
An example of a hybrid procedure involved a 63-year-old woman with a primary complaint of left maxillary region swelling along with recurrent infections. She was treated with more than 30 days of antibiotics prior to examination with computer-assisted tomography. Her condition was nonacute at the time the CT scan was performed. She also had a greater than three-month course of nasal steroid spray and had two courses of primary care prescribed oral steroids. She underwent a hybrid procedure. The balloon sinuplasty remodeled the frontal, maxillary, and sphenoid sinuses. She also underwent a traditional total ethmoidectomy. After 21 months she is doing well without complaints.
Dr. Weiss said that clinicians using sinuplasty need to take time to consolidate their work before moving forward with the developing field. We need to not get ahead of ourselves. It will require good studies to further prove its effectiveness, repeatability and sustainability. It must be done through the peer review process, he said.
I don’t think we have a repeatability issue with this, he said. I have done over 200 of these procedures and although I have been doing them for a long time, I don’t think there is any reason other doctors cannot accomplish the same thing.
Proper Coding for Sinuplasty
Getting reimbursed for sinuplasty requires the use of the proper codes, said Dr. Setzen. Use of pure sinuplasty requires the use of CPT Unlisted Code 31299. In performing the hybrid procedure, Dr. Setzen said the codes are for functional endoscopic sinus surgery:
- 31256 for the maxillary sinus, 31267 if tissue is removed.
- 31287 for the sphenoid sinus, 31288, if tissue is removed.
- 31276 for the frontal sinus.
Dr. Setzen said the professional American Academy of Otolaryngology-Head and Neck Surgery, in its opinion on New Surgery for Sinus Balloon Catheterization, suggested: First and foremost, we feel the physician should code for the work done based on the CPT descriptor for the code.
When sinus endoscopy is used to create a sinusotomy in the frontal, maxillary of sphenoid sinuses whether using forceps, a microdebrider, a laser, or a balloon catheter, there is displacement of bone and mucosa. These various techniques have some variations in time among themselves and between operators but we feel the work is similar enough to justify existing codes when the following conditions are met:
- A sinus endoscope is used to position the balloon prior to and during the cannulation of the ostia and confirming the dilation with the balloon.
- Bone and mucosa must be moved in such a fashion to significantly enlarge the ostium of the sinus addressed.
Dr. Setzen continued, You can see that when we do use the balloon technology these two criteria are being met, so you can use these codes.
Indications for the Procedure
Dr. Setzen said that fears of an unfavorable backlash against sinuplasty due to an abundance of lay news media publicity has been allayed and may actually prove to be a benefit. Many patients are coming into our offices and are asking, ‘Doctor, can you use this new balloon sinuplasty on my sinuses?’
He said that even though some of these patients may not be candidates for sinuplasty, their presentation in the office will give otolaryngologists the opportunity to discuss other forms of endoscopic sinus surgery with those individuals. It may bring a whole slew of nasal sinus patients back to our offices, he said.
The economics surrounding the use of sinuplasty, however, bothered Donald Lanza, MD, a private practice otolaryngologist in St. Petersburg, FL. My concern is that economic forces-and not necessarily science-are driving this at this time. I think that there has to be a somewhat altruistic way in which we have to search our consciousness as to what the actual indication for sinus surgery are. That’s a bigger question than what the indications are for a device.
Dr. Weiss said he agreed that research is still required in the area.
©2007 The Triological Society