How To Use CPT Code 31002

CPT 31002 describes the lavage procedure for the sphenoid sinus. This article will cover the description, official details, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 31002?

CPT 31002 is used to describe a specific procedure involving the sphenoid sinus. This code represents the insertion of a flexible cannula to wash out the contents of the sphenoid sinus. The goal of this procedure is to treat acute or subacute sphenoid sinusitis by irrigating the sinus with saline solution.

2. Official Description

The official description of CPT code 31002 is: ‘Lavage by cannulation; sphenoid sinus.’

3. Procedure

1. The provider prepares the patient and administers anesthesia.
2. A flexible cannula is inserted via the sphenoethmoidal recess into the sphenoid sinus.
3. The provider applies constant pressure to introduce the cannula and irrigates the sinus with saline solution.
4. The contents of the sinus are washed out, and excessive bleeding is controlled with cotton pledgets.
5. The procedure is performed unilaterally, but modifiers may be used for bilateral procedures.

4. Qualifying circumstances

This procedure is indicated for patients with acute or subacute sphenoid sinusitis. The sphenoid sinus is a paired paranasal sinus located deep in the skull, communicating with the nasal cavity. The provider must use a cannula to access and irrigate the sinus, aiming to alleviate inflammation and infection.

5. When to use CPT code 31002

CPT code 31002 should be used when the provider performs the lavage procedure on the sphenoid sinus. It is important to note that this code represents a unilateral service, so modifiers may be necessary for bilateral procedures.

6. Documentation requirements

To support a claim for CPT code 31002, the provider must document the following information:

• Patient’s diagnosis of acute or subacute sphenoid sinusitis
• Details of the lavage procedure, including the use of a cannula and saline solution
• Procedure date and any modifiers used
• Any complications or excessive bleeding and the measures taken to control it
• Signature of the performing provider

7. Billing guidelines

When billing for CPT code 31002, ensure that the procedure is performed on the sphenoid sinus using a cannula for lavage. Modifiers may be necessary for bilateral procedures. It is important to follow payer preferences regarding modifiers RT/LT or modifier 50 for bilateral procedures.

8. Historical information

CPT code 31002 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or changes to the code since its addition.

9. Examples

1. A patient presents with acute sphenoid sinusitis, and the provider performs lavage using a cannula to wash out the sinus.
2. A unilateral lavage procedure is performed on a patient with subacute sphenoid sinusitis to alleviate symptoms and promote healing.
3. The provider performs a lavage procedure on the sphenoid sinus of a patient with chronic sinusitis to improve their overall sinus health.
4. A patient with recurrent sphenoid sinus infections undergoes a lavage procedure to flush out the sinus and prevent further infections.
5. A provider performs a lavage procedure on the sphenoid sinus of a patient with sinusitis that has not responded to other treatments.
6. A unilateral lavage procedure is performed on a patient with sphenoid sinusitis to relieve pain and congestion.
7. A lavage procedure is performed on the sphenoid sinus of a patient with sinusitis to improve their quality of life and reduce the need for medication.
8. A patient with acute sphenoid sinusitis undergoes a lavage procedure to expedite their recovery and alleviate symptoms.
9. The provider performs a lavage procedure on the sphenoid sinus of a patient with chronic sinusitis to improve their overall sinus health.
10. A unilateral lavage procedure is performed on a patient with sphenoid sinusitis to relieve pain and congestion.