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2015.2 Procedures Criteria
Sinusotomy, Maxillary
Sinusotomy, Maxillary
2015.2 Procedures Criteria
PATIENT:
Name
DOB
Facility
PROVIDER: Name
Signature
ID#
GROUP#
Service Date
Fax#
Phone#
Date
NPI/ID#
ICD-10:
CPT®:
Subset: Sinusotomy, Maxillary(1, 2, 3)
Requested Service: Sinusotomy, Maxillary
Age: Age ≥ 18
INSTRUCTIONS: Choose one of the following options and continue to the appropriate section
10. Acute maxillary rhinosinusitis, complicated (urgent)
20. Chronic maxillary rhinosinusitis
30. Fracture of orbital floor or malar eminence by CT or x-ray
40. Ligation of internal maxillary artery (IMA) (urgent)
50. Maxillary sinus mass by CT or MRI
60. Recurrent acute maxillary rhinosinusitis
10. Acute maxillary rhinosinusitis, complicated (urgent)
1. Rhinosinusitis confirmed by CT, Choose all that apply:(4)
A) Air fluid levels
B) Opacification
C) Other clinical information (add comment)
If 1 or more options A or B selected and option C not selected, then go to question 2
No other options lead to the requested service
2. Complications or complicating factors, Choose all that apply:(5)
InterQual® criteria (IQ) is confidential and proprietary information and is being provided to you solely as it pertains to the information requested. IQ may
contain advanced clinical knowledge which we recommend you discuss with your physician upon disclosure to you. Use permitted by and subject to
license with McKesson Corporation and/or one of its subsidiaries. IQ reflects clinical interpretations and analyses and cannot alone either (a) resolve
medical ambiguities of particular situations; or (b) provide the sole basis for definitive decisions. IQ is intended solely for use as screening guidelines with
respect to medical appropriateness of healthcare services. All ultimate care decisions are strictly and solely the obligation and responsibility of your
health care provider. InterQual® and CareEnhance® Review Manager © 2015 McKesson Corporation and/or one of its subsidiaries. All Rights
Reserved. CPT only © 2014 American Medical Association. All Rights Reserved.
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2015.2 Procedures Criteria
Sinusotomy, Maxillary
Sinusotomy, Maxillary
10. Acute maxillary rhinosinusitis, complicated (urgent) (Continued...)
A) Immunocompromised host(6)
B) Focal neurologic finding(7)
C) Facial cellulitis
D) Orbital cellulitis or abscess by physical examination or CT
E) Periorbital abscess by physical examination or CT
F) Meningitis by lumbar puncture (LP)(8)
G) Intracranial abscess by CT or MRI(9)
H) Cavernous sinus thrombosis by CT or MRI(10)
I) Other clinical information (add comment)
If 1 or more options A, B, C, D, E, F, G or H selected and option I not selected, then the rule is satisfied; you may stop here
(Outpatient)
No other options lead to the requested service
20. Chronic maxillary rhinosinusitis
1. Symptoms ≥ 12 weeks(11)
Yes
No
If option Yes selected, then go to question 2
No other options lead to the requested service
2. Rhinosinusitis confirmed by CT, Choose all that apply:(12)
A) Air fluid levels
B) Mucosal thickening > 2 mm
C) Opacification
D) Other clinical information (add comment)
If 1 or more options A, B or C selected and option D not selected, then go to question 3
No other options lead to the requested service
3. Treatment during course of illness, Choose all that apply:
A) Antibiotic treatment ≥ 3 weeks(13)
B) Intranasal corticosteroid spray ≥ 3 weeks or intranasal corticosteroid spray contraindicated or not tolerated(14, 15)
C) Other clinical information (add comment)
If the number of options selected is 2 and option C not selected, then go to question 4
No other options lead to the requested service
4. Continued symptoms or findings after treatment
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2015.2 Procedures Criteria
Sinusotomy, Maxillary
Sinusotomy, Maxillary
20. Chronic maxillary rhinosinusitis (Continued...)
Yes
No
If option Yes selected, then the rule is satisfied; you may stop here (Outpatient)
No other options lead to the requested service
30. Fracture of orbital floor or malar eminence by CT or x-ray
There are no questions for the requested service.
40. Ligation of internal maxillary artery (IMA) (urgent)
1. Choose one:
A) Epistaxis uncontrolled by anterior or posterior packing
B) Epistaxis and patient cannot tolerate packing
C) Epistaxis and known coagulopathy(16)
D) Other clinical information (add comment)
If option A or C selected, then the rule is satisfied; you may stop here (Outpatient)
If option B selected, then go to question 2
No other options lead to the requested service
2. Choose one:
A) Cardiopulmonary disease
B) Uncontrolled pain from packing
C) Other clinical information (add comment)
If option A or B selected, then the rule is satisfied; you may stop here (Outpatient)
No other options lead to the requested service
50. Maxillary sinus mass by CT or MRI
There are no questions for the requested service.
60. Recurrent acute maxillary rhinosinusitis
1. Choose all that apply:
A) ≥ 4 episodes within 1 year(17)
B) Maxillary sinus involvement confirmed by CT(18)
C) Other clinical information (add comment)
If the number of options selected is 2 and option C not selected, then the rule is satisfied; you may stop here (Outpatient)
No other options lead to the requested service
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2015.2 Procedures Criteria
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Sinusotomy, Maxillary
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2015.2 Procedures Criteria
Sinusotomy, Maxillary
Sinusotomy, Maxillary
Notes
(1)
I/O Setting: Outpatient
(2)
These criteria include the following procedures:
Maxillary Antrostomy
Nasal Antrostomy
(3)
InterQual® criteria are derived from the systematic, continuous review and critical appraisal of the most current evidence-based
literature and include input from our independent panel of clinical experts. The content is based on a variety of references which are
cited at specific criteria points throughout the subset.
(4)
History and physical examination can readily diagnose acute rhinosinusitis. Imaging with CT is indicated for patients with complicating
factors (e.g., immunocompromised, focal neurologic findings), atypical symptoms, or for surgical planning. Air-fluid levels or complete
sinus opacification seen on CT is diagnostic of acute rhinosinusitis (Cornelius et al., J Am Coll Radiol 2013, 10: 241-6; Fokkens et al.,
Rhinology 2012, 50: 1-12). < font color="#cc6600">.
(5)
Because acute rhinosinusitis can extend intracranially and from the paranasal sinuses into the orbit, facial and orbital cellulitis,
intracranial abscesses, and meningitis should be urgently evaluated with CT, MRI, or both to confirm the diagnosis. Prompt treatment
is then recommended (Cornelius et al., J Am Coll Radiol 2013, 10: 241-6; American College of Radiology (ACR), ACR Appropriateness
Criteria: Sinusitis - Child. 2012; Meara, Oral Maxillofac Surg Clin North Am 2012, 24: 487-96; Moffett, Oral Maxillofac Surg Clin North
Am 2012, 24: 469-86).
(6)
Immunocompromised patients are individuals whose immune system is impaired either because of a primary underlying
immunodeficiency disorder or because of the administration of medications that suppress the immune response, putting them at risk
for developing opportunistic infections.
(7)
Focal neurologic finding refers to a specific deficit that corresponds to a particular area of the brain (e.g., right arm weakness from a
left motor cortex insult).
(8)
Def: Meningitis is inflammation of the membranes covering the brain and spinal cord usually caused by one of a variety of infectious
agents including bacteria, viruses, or fungi.
(9)
Intracranial abscesses include epidural, subdural, cerebral, and cerebellar abscesses.
(10)
CT and MRI are the modalities of choice to confirm the diagnosis of cavernous sinus thrombosis and to differentiate it from orbital
cellulitis, which may have a similar clinical presentation (Desa and Green, J Oral Maxillofac Surg 2012, 70: 2085-91).
(11)
A compilation of several guidelines defines chronic rhinosinusitis as the presence of two or more signs or symptoms of sinusitis
(e.g., purulent nasal discharge; nasal obstruction, blockage, or congestion; facial pain, pressure, or fullness; decreased or altered
sense of smell) for at least 12 weeks and documented persistent inflammation (Meltzer and Hamilos, Mayo Clin Proc 2011, 86: 42743).
(12)
CT remains the gold standard diagnostic test for confirming chronic rhinosinusitis by documenting inflammation. CT also provides
information about sinus anatomy, the ostiomeatal complex, nasal septum, turbinates, and the extent of mucosal thickening (Cornelius
et al., J Am Coll Radiol 2013, 10: 241-6).
(13)
The most common pathogens found in chronic rhinosinusitis are Staphylococcus aureus, Pseudomonas, and Enterobacteriaceae
species. Antimicrobials with broad-spectrum coverage that targets gram-negative organisms are indicated prior to consideration of
surgery (Kaplan, Can Fam Physician 2013, 59: 1275-81, e528-34; Desrosiers et al., Allergy Asthma Clin Immunol 2011, 7: 2).
(14)
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Sinusotomy, Maxillary
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Intranasal corticosteroids are widely used in the treatment of chronic rhinosinusitis to relieve the inflammation of the nasal mucosa,
thereby reducing swelling and opening the obstructed sinus cavities (Piromchai et al., Int J Gen Med 2013, 6: 453-64).
(15)
Contraindications to intranasal corticosteroid spray include cataracts and glaucoma, as it may worsen intraocular pressure.
(16)
Patients with coagulopathy who are receiving warfarin therapy, ASA, NSAIDs, or steroids have an increased risk of bleeding. These
coagulopathies should be corrected if possible prior to surgery (Solares et al., Otolaryngol Clin North Am 2010, 43: 817-25).
(17)
Recurrent acute rhinosinusitis is defined as at least four episodes of acute bacterial rhinosinusitis within one year, with an absence of
signs or symptoms of rhinosinusitis between episodes. The microbiology of recurrent acute rhinosinusitis is similar to that of acute
bacterial rhinosinusitis and warrants the same treatment. Patients with recurrent acute rhinosinusitis who undergo surgery have
a decreased number of acute infections, antibiotic courses, and sinus-related physician visits (Poetker et al., Am J Rhinol 2008, 22:
329-33).
(18)
CT is considered the gold standard for evaluation of the paranasal sinuses and allows for evaluation of inflammatory and mucosal
disease, nasal polyposis, and anatomic obstruction. CT is indicated to determine the extent of the disease prior to sinus surgery
(Setzen et al., Otolaryngol Head Neck Surg 2012, 147: 808-16).
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Sinusotomy, Maxillary
ICD-10-CM (circle all that apply): C31.0, J01.00, J01.01, J32.0, Other___________
ICD-10-PCS (circle all that apply): 095Q0ZZ, 095Q3ZZ, 095Q4ZZ, 095R0ZZ, 095R3ZZ, 095R4ZZ, 099Q00Z, 099Q0ZZ, 099R00Z,
099R0ZZ, 09BQ0ZZ, 09BQ3ZZ, 09BQ4ZZ, 09BR0ZZ, 09BR3ZZ, 09BR4ZZ, 09CQ0ZZ, 09CQ3ZZ, 09CQ4ZZ, 09CR0ZZ, 09CR3ZZ,
09CR4ZZ, 09DQ0ZZ, 09DQ3ZZ, 09DQ4ZZ, 09DR0ZZ, 09DR3ZZ, Other___________
CPT® (circle all that apply): 31020, 31030, 31032, 31050, 31051, 31256, 31267, 31276, Other___________
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