How To Use CPT Code 31051

CPT 31051 describes a specific procedure performed on the sphenoid sinus, involving either mucosal stripping or removal of polyps. This article will provide an overview of CPT code 31051, including its official description, the procedure itself, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, and examples.

1. What is CPT Code 31051?

CPT 31051 is a code used to describe a procedure performed on the sphenoid sinus. It involves either mucosal stripping or removal of polyps. This code is specifically used when the provider makes an incision in the sphenoid sinus and performs the necessary steps to strip the mucosa or remove polyps.

2. Official Description

The official description of CPT code 31051 is: ‘Sinusotomy, sphenoid, with or without biopsy; with mucosal stripping or removal of polyp(s).’ This code represents the surgical procedure performed on the sphenoid sinus, which includes either stripping the mucosa or removing polyps.

3. Procedure

1. During the procedure, the provider begins by making an intraoral incision to access the sphenoid sinus.
2. Next, the provider severs the septal cartilage of the nose to advance towards the sphenoid sinus.
3. The front wall of the sinus is then removed, allowing the diseased contents to drain.
4. If present, the provider removes any polyps from the sphenoid sinus or strips the mucosal lining.
5. The septal cartilage is restored to its original position, and the incision in the mouth is closed in a single layer.

4. Qualifying circumstances

CPT 31051 is performed on patients who require treatment for conditions affecting the sphenoid sinus. The procedure is typically performed when there is a need for mucosal stripping or removal of polyps. The provider must assess the patient’s condition and determine the necessity of this specific procedure.

5. When to use CPT code 31051

CPT code 31051 should be used when the provider performs a sinusotomy on the sphenoid sinus and includes either mucosal stripping or removal of polyps. This code is appropriate when the procedure is performed on one side only. If the procedure is performed bilaterally, modifier 50 should be appended, or modifiers RT/LT can be used based on payer preference.

6. Documentation requirements

To support a claim for CPT code 31051, the provider must document the following information:

• Patient’s diagnosis and the need for the specific procedure
• Details of the procedure performed, including whether mucosal stripping or polyp removal was done
• Date of the procedure
• Any additional relevant information or complications encountered during the procedure
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT code 31051, it is important to ensure that the procedure performed aligns with the code description. This code should not be reported if the provider performs a sphenoid sinusotomy without mucosal stripping or polyp removal; in such cases, CPT code 31050 should be used instead. Additionally, consider payer preferences for reporting bilateral procedures using modifiers RT/LT or modifier 50.

8. Historical information

CPT code 31051 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 sphenoid sinusotomy with mucosal stripping for a patient with chronic sinusitis.
2. During a surgical procedure, the provider performs a sphenoid sinusotomy and removes polyps from the sphenoid sinus of a patient with nasal polyps.
3. A patient with recurrent sinus infections undergoes a sphenoid sinusotomy with mucosal stripping to alleviate their symptoms.
4. For a patient with a suspected tumor in the sphenoid sinus, the provider performs a sphenoid sinusotomy with biopsy and mucosal stripping.
5. A provider performs a sphenoid sinusotomy with polyp removal for a patient with chronic rhinosinusitis.
6. During a surgical procedure, the provider performs a sphenoid sinusotomy and removes polyps from the sphenoid sinus of a patient with allergic fungal sinusitis.
7. A patient with sphenoid sinus disease undergoes a sphenoid sinusotomy with mucosal stripping to improve their sinus health.
8. For a patient with chronic headaches related to sphenoid sinus issues, the provider performs a sphenoid sinusotomy with polyp removal.
9. A provider performs a sphenoid sinusotomy with mucosal stripping for a patient with recurrent sinus infections.
10. During a surgical procedure, the provider performs a sphenoid sinusotomy and removes polyps from the sphenoid sinus of a patient with cystic fibrosis.