Z48.813 — Encounter for surgical aftercare following surgery on the respiratory system
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- "History must include specific symptoms and findings obtained by the otolaryngologist. A historical diagnosis labeled 'sinusitis' by the patient or unsubstantiated symptoms alone is not sufficient documentation to establish this as a chronic illness."
- "The clinician should confirm a clinical diagnosis of chronic rhinosinusitis (CRS) with objective documentation of sinonasal inflammation, which may be accomplished using anterior rhinoscopy, nasal endoscopy or computed tomography."
- "Failure of optimal medical management (describe) for acute or chronic ethmoid sinusitis" and similar statements requiring documentation of failed medical therapy where listed in clinical indicators.
- "For endoscopic surgery in children... Failure of medical management for chronic rhinosinusitis or recurrent acute rhinosinusitis, possibly in addition to other disorders..." and the recommendation that adenoidectomy be considered prior to pediatric sinus surgery (document prior interventions and duration).
Key Coverage Criteria
- General coverage statement: "Diagnostic nasal/sinus endoscopy, functional endoscopic sinus surgery and turbinectomy ... are considered medically necessary when the associated signs and symptoms or diagnoses are listed in the Coding Information section for ANY of the following: diagnostic nasal/sinus endoscopy; functional endoscopic sinus surgery (FESS); turbinectomy."
- Diagnostic nasal/sinus endoscopy — clinical/narrative indications (from General Background / literature): "evaluation of nasal blockage, nasal and sinus infection (rhinosinusitis), osteomyelitis, sinusitis, nasal polyps, mucocele nasal tumors, nasal bleeding, anosmia, hyposmia, parosmia, rhinorrhea, obstructive sleep apnea, choanal atresia, fracture, foreign body, barotrauma and cerebrospinal leak."
- Diagnostic nasal/sinus endoscopy — other accepted uses: "evaluation of chronic sinonasal symptoms; assessment of interval response to medical or surgical therapy; monitoring for recurrence of sinusitis and/or nasal polyps; evaluation and management of epistaxis; performance of endoscopically guided cultures; assessment of facial pain suggestive of nasal origin; evaluation of clear rhinorrhea suggestive of cerebrospinal fluid leak; performance of initial diagnosis and interval surveillance for si [...]
- FESS — clinical/narrative indications: "chronic sinusitis and recurrent sinusitis refractory to treatment, removal of polyps and mucoceles, excision of tumors, treatment of cerebrospinal fluid leak, barotrauma, orbital decompression, optic nerve decompression, dacryocystorhinostomy, choanal atresia repair, removal of foreign bodies and control of bleeding."
- Turbinectomy — clinical/narrative indications: "to clear an obstruction of the turbinate(s), when conservative medical treatment such as nasal steroids, has failed."
- Professional society-based indications (AAO-HNS / AAAI / ACR summarized): allergic fungal rhinosinusitis; CRSsNP or CRSwNP with persistent symptoms and objective evidence refractory to optimal medical treatment; complications of sinusitis (orbit, skull base extension); mucocele; recurrent acute rhinosinusitis (RARS); sinonasal polyposis with nasal airway obstruction or suboptimal asthma control; unilateral paranasal sinus opacification consistent with chronic rhinosinusitis, fungus ball, benign [...]
1 Active Policy
CIGNA-FESS — Diagnostic Nasal/Sinus Endoscopy, Functional Endoscopic Sinus Surgery (FESS) and Turbinectomy - (0554)
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