How To Use CPT Code 31200
CPT 31200 describes the excision procedure on the accessory sinuses known as ethmoidectomy. 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 31200?
CPT 31200 is a code used to describe the excision procedure on the accessory sinuses, specifically the anterior ethmoid sinus. This procedure involves making an intranasal incision to gain access to the anterior ethmoid sinus and removing any diseased contents present in that area.
2. Official Description
The official description of CPT code 31200 is: ‘Ethmoidectomy; intranasal, anterior.’ This procedure involves the provider making an intranasal incision to gain access to the anterior ethmoid sinus and removing all diseased contents from that area.
3. Procedure
- The provider begins by making an intranasal incision to gain access to the middle turbinate.
- If necessary, the middle turbinate may be partially resected to remove any obstructions.
- A small noncutting instrument, such as a curette, is used to break into the anterior cells of the ethmoid sinus.
- The provider then removes the diseased contents of the anterior ethmoid sinus and allows for sinus drainage.
- In some cases, the nasal area may be packed with gauze.
4. Qualifying circumstances
CPT 31200 is performed when there is a need to remove diseased contents from the anterior ethmoid sinus. This procedure is typically done on patients who have conditions affecting the ethmoid sinus, which is located between the nose and the eyes. The provider must make an intranasal incision and gain access to the anterior ethmoid sinus to perform the excision.
5. When to use CPT code 31200
CPT code 31200 should be used when the provider is performing an intranasal, anterior ethmoidectomy. This code is specifically for the excision procedure on the anterior ethmoid sinus. If the provider is performing a total intranasal ethmoidectomy, CPT code 31201 should be used. If the provider is performing a total extranasal ethmoidectomy, CPT code 31205 should be used.
6. Documentation requirements
To support a claim for CPT code 31200, the provider must document the following information:
- Patient’s diagnosis and the need for the ethmoidectomy
- Details of the procedure performed, including the intranasal incision and removal of diseased contents
- Any additional procedures performed, such as partial resection of the middle turbinate
- Any complications or unexpected findings during the procedure
- Post-procedure care instructions, including the use of nasal packing if applicable
- Signature of the provider performing the procedure
7. Billing guidelines
When billing for CPT code 31200, ensure that the procedure performed is an intranasal, anterior ethmoidectomy. This code represents a unilateral service, meaning it is performed on one side. If the procedure is performed bilaterally, append modifier 50. Alternatively, use modifiers RT/LT based on payer preference. It is important to note that CPT code 31200 should not be reported with other codes such as CPT codes 31201 or 31205.
8. Historical information
CPT code 31200 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
- A patient with chronic sinusitis undergoes an intranasal, anterior ethmoidectomy to remove diseased contents from the anterior ethmoid sinus.
- A provider performs an ethmoidectomy on a patient with recurrent nasal polyps to alleviate symptoms and improve breathing.
- An individual with a history of ethmoid sinus tumors undergoes an intranasal, anterior ethmoidectomy for tumor removal.
- A patient with ethmoid sinus cysts undergoes an excision procedure to remove the cysts and alleviate symptoms.
- A provider performs an intranasal, anterior ethmoidectomy on a patient with ethmoid sinusitis to improve sinus drainage and reduce inflammation.
