CPT Code 31256 | Description & Clinical Information

CPT 31256 describes a medical procedure in which the healthcare provider utilizes an endoscope to enter the nasal cavity, creates an incision in the uncinate process to access the maxillary sinus, and subsequently opens the maxillary sinus.

Official Description

The CPT book defines CPT code 31256 as: “Nasal/sinus endoscopy, surgical, with maxillary antrostomy”.

Billing Guidelines

Do not code 31256 together with 31233, 31237, 31267, or 31295 if they were performed on the same side (use CPT before each number).

Clinical Information

The procedure described by CPT code 31256 is a common surgical technique used to treat chronic maxillary sinusitis. This condition is characterized by inflammation and swelling of the maxillary sinuses, causing pressure, pain, congestion, and other uncomfortable symptoms. The goal of the procedure is to relieve the symptoms by draining infection from the affected sinuses.

Before the procedure begins, the patient is prepped and anesthetized to minimize discomfort and ensure safety during the procedure. The provider then inserts a rigid or flexible endoscope into the nasal cavity to gain access to the maxillary sinuses. This tool allows the provider to see inside the nose and sinuses and perform the necessary steps of the procedure with precision.

The provider then shifts the middle meatus, which is a tunnellike structure in the middle of the nose, toward the maxillary sinus. This maneuver is crucial to gaining access to the sinuses and removing any blockages that could prevent proper drainage. The provider then advances to the uncinate process, which is a thin bone that forms the lateral wall of the nasal cavity and separates it from the maxillary sinus.

The provider then dislocates the free higher and central edges of the uncinate process, which allows them to gain access to the maxillary sinus ostium, which is the opening to the sinus. This step is vital to the success of the procedure, as it enables the provider to remove the infected material that is causing the patient’s symptoms.

Once the provider has access to the maxillary sinus ostium, they use cutting forceps to enlarge the opening. This step allows for better drainage of the infected material from the sinus, leading to quicker healing and relief of symptoms. The provider then retains the position of the uncinate process to ensure that the opening remains clear.

Finally, the provider withdraws the endoscope and packs the patient’s nose with gauze to prevent any further bleeding. The patient may experience some discomfort and pain after the procedure, but these symptoms should subside over time as the healing process occurs.

In conclusion, the CPT code 31256 procedure is a safe and effective method for treating chronic maxillary sinusitis. The procedure is minimally invasive, and patients can expect to experience relief from their symptoms soon after the procedure is complete. If you are experiencing symptoms of chronic maxillary sinusitis, talk to your healthcare provider to determine if this procedure could be right for you.

Return to all the CPT codes for endoscopy procedures on the accessory sinuses.

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