How To Use CPT Code 31032

CPT 31032 describes a surgical procedure known as sinusotomy, specifically the radical (Caldwell-Luc) approach, which involves the removal of antrochoanal polyps. This article will provide an overview of the code, including its official description, the procedure itself, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, and similar codes to CPT 31032.

1. What is CPT Code 31032?

CPT 31032 is a code used to describe a surgical procedure called sinusotomy. More specifically, it refers to the radical (Caldwell-Luc) approach, which involves the removal of antrochoanal polyps. This procedure is performed to improve drainage from the maxillary sinus to the nose and is commonly used to treat chronic maxillary sinusitis or when a tumor is present below the eye.

2. Official Description

The official description of CPT code 31032 is: ‘Sinusotomy, maxillary (antrotomy); radical (Caldwell-Luc) with removal of antrochoanal polyps.’ This code can be used to report the surgical removal of antrochoanal polyps using the radical approach, which includes creating a window connecting the maxillary sinus to the nose to improve drainage.

3. Procedure

1. The provider begins by making an incision in the upper gums, exposing the canine fossa.
2. Using an osteotome, the provider enters the maxillary sinus and removes the entire mucosa from the antrum, creating a window that connects the maxillary sinus to the nose.
3. The provider then removes any antrochoanal polyps and other diseased material present in the maxillary sinus.
4. Finally, the gum incision is closed with a single layer, taking care to avoid injury to the infraorbital nerve.

4. Qualifying circumstances

CPT 31032 is typically performed when a patient has chronic maxillary sinusitis or when a tumor is present below the eye. The procedure involves the removal of antrochoanal polyps, which are solitary polyps that arise in the maxillary sinus and enlarge the sinus ostium. It is important to note that this code represents a unilateral service, meaning it is performed on one side. If the procedure is performed bilaterally, modifier 50 should be appended to the code.

5. When to use CPT code 31032

CPT code 31032 should be used when a provider performs a radical maxillary sinusotomy with the removal of antrochoanal polyps. It is important to ensure that the procedure meets the specific criteria outlined in the code description. If the procedure does not involve the removal of antrochoanal polyps, a different code, such as 30130, should be used.

6. Documentation requirements

When reporting CPT code 31032, the provider must document the following information:

• Patient’s diagnosis, indicating chronic maxillary sinusitis or the presence of a tumor below the eye
• Details of the procedure performed, including the radical (Caldwell-Luc) approach and the removal of antrochoanal polyps
• Date of the procedure
• Any complications or additional findings during the procedure
• Signature of the performing provider

7. Billing guidelines

When billing for CPT code 31032, it is important to ensure that the procedure meets the specific criteria outlined in the code description. The procedure should be reported as a unilateral service unless performed bilaterally, in which case modifier 50 should be appended to the code. It is also important to note that CPT code 31032 should not be reported with other codes such as 30130. Additionally, it is recommended to review payer preferences regarding the use of modifiers RT/LT for bilateral procedures.

8. Historical information

CPT code 31032 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 provider performs a radical maxillary sinusotomy with the removal of antrochoanal polyps for a patient with chronic maxillary sinusitis.
2. During the procedure, the provider discovers a tumor below the eye and performs a radical maxillary sinusotomy with the removal of antrochoanal polyps to address the condition.
3. A patient presents with chronic maxillary sinusitis, and the provider performs a radical maxillary sinusotomy with the removal of antrochoanal polyps to alleviate the symptoms.
4. A provider performs a radical maxillary sinusotomy with the removal of antrochoanal polyps for a patient with a tumor below the eye, aiming to remove the tumor and improve drainage.
5. During the procedure, the provider identifies the presence of antrochoanal polyps and performs a radical maxillary sinusotomy with their removal to address the condition.
6. A patient with chronic maxillary sinusitis undergoes a radical maxillary sinusotomy with the removal of antrochoanal polyps to alleviate the symptoms and improve drainage.
7. A provider performs a radical maxillary sinusotomy with the removal of antrochoanal polyps for a patient with a tumor below the eye, aiming to remove the tumor and improve drainage.
8. During the procedure, the provider discovers the presence of antrochoanal polyps and performs a radical maxillary sinusotomy with their removal to address the condition.
9. A patient with chronic maxillary sinusitis undergoes a radical maxillary sinusotomy with the removal of antrochoanal polyps to alleviate the symptoms and improve drainage.
10. A provider performs a radical maxillary sinusotomy with the removal of antrochoanal polyps for a patient with a tumor below the eye, aiming to remove the tumor and improve drainage.