Functional Endoscopic Sinus Surgery (FESS)

CPT 31255

Approach Endoscopic

Add-on / Variant CPTs

31256 — Maxillary antrostomy with removal of tissue
31276 — Frontal sinus exploration with removal of tissue
31288 — Sphenoid sinusotomy
31237 — Nasal/sinus endoscopy with biopsy
31240 — Nasal/sinus endoscopy with concha bullosa resection

Preoperative Diagnosis:

Chronic rhinosinusitis [with / without] nasal polyps, refractory to medical management

Postoperative Diagnosis:

Same

Procedure Performed:

Bilateral functional endoscopic sinus surgery (maxillary antrostomy, anterior and posterior ethmoidectomy [, frontal sinusotomy, sphenoidotomy])

Attending Surgeon:

[Attending name], MD

First Assistant:

[Resident/Fellow/PA name]

Anesthesia:

General endotracheal
Patient supine, head of bed elevated 15-20 degrees. Image-guided navigation system registered to preoperative CT.

Indications:

Patient presents with [chronic rhinosinusitis / nasal polyposis / recurrent acute sinusitis] refractory to [X months] of maximal medical therapy including [intranasal steroids, saline irrigations, oral antibiotics, oral steroids]. CT sinuses demonstrates [Lund-Mackay score X] with [obstruction of / disease in] [osteomeatal complex / ethmoid / maxillary / frontal / sphenoid sinuses]. Image-guided navigation used for safety in [posterior ethmoids / frontal / sphenoid]. Risks including bleeding, orbital injury, CSF leak, anosmia, and recurrence discussed. Consent obtained.

Findings:

Bilateral nasal endoscopy confirmed [polyps / edematous mucosa / purulence] in [osteomeatal complex / ethmoid / maxillary sinuses]. [Uncinate process hypertrophied.] Image-guided navigation confirmed anatomy correlated with CT.

Description of Procedure:

Nasal decongestion achieved with [oxymetazoline-soaked pledgets and 4% cocaine topical / 1% lidocaine with 1:100,000 epinephrine injected into lateral nasal wall and middle turbinate]. Image-guided navigation system was registered to preoperative CT and accuracy confirmed.
A 0-degree [and 30-degree] rigid nasal endoscope was used. The procedure was performed bilaterally.
MAXILLARY ANTROSTOMY: The uncinate process was resected with a sickle knife and through-cutting forceps. The natural maxillary ostium was identified and enlarged posteriorly and inferiorly with a backbiting forceps, creating a [1.5-2 cm] antrostomy. Mucosal disease and purulence evacuated.
ETHMOIDECTOMY: Anterior ethmoid cells were opened systematically, following the skull base from anterior to posterior. The ground lamella was perforated, entering the posterior ethmoid. Posterior ethmoid cells were exenterated. The skull base (lamina papyracea laterally, skull base superiorly) was identified and preserved. Navigation confirmed safe margins.
[FRONTAL SINUSOTOMY: The frontal recess was opened with frontal seekers and through-cutting forceps under navigation guidance.]
[SPHENOIDOTOMY: The sphenoid face was identified medial to the superior turbinate. The ostium was enlarged with a Kerrison rongeur. Disease evacuated.]
Hemostasis achieved with [Afrin-soaked pledgets / thrombin-soaked Gelfoam]. [Absorbable packing (FloSeal / Nasopore) placed.] Patient tolerated the procedure well.

Complications:

None

Specimens:

[Sinus contents sent to pathology / Nasal polyps sent to pathology / Culture sent]

Estimated Blood Loss:

Minimal

Drains:

[Absorbable hemostatic packing placed bilaterally / No packing]

Disposition:

Patient taken to PACU in stable condition. Discharged same day.

Epic SmartPhrase Version

PREOPERATIVE DIAGNOSIS: Chronic rhinosinusitis [with / without] nasal polyps, refractory to medical management
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Bilateral functional endoscopic sinus surgery: maxillary antrostomy, anterior and posterior ethmoidectomy [, frontal sinusotomy, sphenoidotomy]
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal

INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with chronic rhinosinusitis [with / without] nasal polyps refractory to *** months of maximal medical therapy including intranasal steroids, saline irrigations, and oral antibiotics. CT sinuses shows Lund-Mackay score *** with obstruction of the osteomeatal complex. Image-guided navigation utilized for safety in posterior ethmoids and sphenoid. Risks including bleeding, orbital injury, CSF leak, and recurrence were discussed. Informed consent obtained.

FINDINGS: Bilateral nasal endoscopy confirmed [polyps / edematous mucosa / purulence] in the osteomeatal complex and ethmoid sinuses. Uncinate process hypertrophied. Image-guided navigation confirmed anatomy correlated with preoperative CT.

DESCRIPTION OF PROCEDURE:
Nasal decongestion achieved with oxymetazoline pledgets and 1% lidocaine with 1:100,000 epinephrine injected into lateral nasal wall. Image-guided navigation registered to preoperative CT; accuracy confirmed. A 0-degree rigid nasal endoscope was used bilaterally. MAXILLARY ANTROSTOMY: Uncinate process resected; natural ostium enlarged with backbiting forceps creating a 1.5–2 cm antrostomy; disease evacuated. ETHMOIDECTOMY: Anterior ethmoid cells opened systematically skull-base to posterior; ground lamella perforated; posterior ethmoid cells exenterated; skull base and lamina papyracea identified and preserved. [FRONTAL SINUSOTOMY: Frontal recess opened under navigation guidance.] [SPHENOIDOTOMY: Sphenoid face opened medial to superior turbinate; ostium enlarged; disease evacuated.] Hemostasis achieved with Afrin-soaked pledgets. Absorbable packing placed bilaterally. Patient tolerated the procedure well.

ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: [Sinus contents / nasal polyps to pathology; culture sent]
COMPLICATIONS: None
DRAINS: Absorbable hemostatic packing placed bilaterally
DISPOSITION: Patient taken to PACU in stable condition. Discharged same day.

Signed: .ME, .MYDEGREE
.TODAY

Variants

Revision FESS

Document prior surgery and altered anatomy. Navigation particularly important. Document landmarks used and any adhesions or scarring encountered.

Draf II/III frontal sinusotomy (modified Lothrop)

For recalcitrant frontal sinusitis. Document removal of frontal intersinus septum, floor of frontal sinus, and superior septum creating common cavity.

Balloon sinuplasty

Minimally invasive technique using balloon dilation of ostia. No tissue removal. Document sinuses treated and balloon size.

Charting Tips

Document image-guided navigation use and registration accuracy
CPT codes are sinus-specific. List each sinus individually for accurate billing.
State each compartment operated on (maxillary, anterior ethmoid, posterior ethmoid, frontal, sphenoid)
Document visualization and preservation of skull base, lamina papyracea, and orbital contents
If CSF leak is suspected intraoperatively, document fluorescein use, leak identification, and repair
Send polyps to pathology. Eosinophilic, fungal, or inverted papilloma on histology changes management.

Billing Tips

FESS codes are additive. Bill each sinus addressed separately. 31254 for partial ethmoidectomy (4.16 wRVU), 31255 for total ethmoidectomy (5.61 wRVU), 31256 for maxillary antrostomy (3.03 wRVU), 31267 for maxillary antrostomy with tissue removal (4.56 wRVU). All have 0-day global periods.
Use the highest applicable ethmoidectomy code (partial vs. total) plus any additional sinus codes. Do not bill 31254 and 31255 for the same side. Bill only the total ethmoidectomy if total is performed.
Sphenoid sinus surgery (31287, 31288) and frontal recess dissection (31276) are separately billable codes when those sinuses are addressed. Document each sinus entered and the procedure performed in each.
0-day global period: nasal packing removal, nasal rinse education, and first postoperative visit are not bundled. They can be billed as separate E/Ms. Document a new evaluation at each follow-up visit.
Bilateral FESS: bill each side separately using modifier -50 (bilateral) or list each sinus procedure twice. Document bilateral findings and bilateral procedures performed to support billing both sides.