How To Use CPT Code 31201

CPT 31201 describes the excision procedure for the ethmoid sinus using an intranasal approach. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 31201?

CPT 31201 is a code used to describe the excision procedure for the ethmoid sinus. It involves accessing the anterior and posterior ethmoid sinuses through an intranasal approach. The provider removes diseased tissues and may apply drains if necessary.

2. Official Description

The official description of CPT code 31201 is the “Ethmoidectomy; intranasal, total.” This procedure involves the removal or excision of cells in the ethmoid bone or ethmoid sinus using an intranasal approach.

3. Procedure

1. The provider prepares the patient and administers anesthesia.
2. An intranasal incision is made by the provider.
3. The provider incises the mucosa and advances into the anterior cells of the ethmoid sinus.
4. Using a curette, the provider removes the diseased tissues from the anterior cells.
5. The provider then dissects the posterior cells and removes diseased tissues from the posterior aspect using curettes.
6. The removed tissues are sent to pathology for further analysis.
7. To prevent further bleeding, the provider packs the nasal incision with gauze.

4. Qualifying circumstances

CPT 31201 is performed when there is a need to remove or excise cells in the ethmoid bone or ethmoid sinus. This procedure is typically done to address conditions such as polyps or other diseased tissues in the ethmoid sinus. It is important to note that this code represents a unilateral service, meaning it is performed on one side of the nasal cavity. If the procedure is performed bilaterally, modifier 50 or RT/LT should be appended.

5. When to use CPT code 31201

CPT code 31201 should be used when the provider performs an intranasal ethmoidectomy to remove or excise cells in the ethmoid bone or ethmoid sinus. It is important to use this code only when the procedure is performed using an intranasal approach. If the provider performs a total ethmoidectomy using an extranasal approach, CPT code 31205 should be used instead.

6. Documentation requirements

To support a claim for CPT code 31201, the provider must document the following information:

• Patient’s diagnosis necessitating the ethmoidectomy
• Details of the procedure, including the intranasal approach and the specific cells or tissues removed
• Date of the procedure
• Any additional procedures performed during the same session
• Any complications or unexpected findings
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT code 31201, ensure that the procedure is performed using an intranasal approach. If the procedure is performed bilaterally, append modifier 50 or RT/LT as required by the payer. It is important to note that CPT code 31201 should not be reported with other codes such as CPT codes 31205. Additional tips for reporting CPT code 31201 include considering the location of the testing, which may affect how the procedure is coded.

8. Historical information

CPT code 31201 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 an intranasal ethmoidectomy to remove polyps from the ethmoid sinus of a patient.
2. Using an intranasal approach, a provider excises diseased tissues from the ethmoid sinus to address chronic sinusitis in a patient.
3. A unilateral ethmoidectomy is performed by a provider to remove cells in the ethmoid bone that are causing obstruction in a patient.
4. A provider uses an intranasal approach to perform an ethmoidectomy and remove diseased tissues in the ethmoid sinus of a patient with recurrent nasal polyps.
5. To address chronic rhinosinusitis, a provider performs an intranasal ethmoidectomy to remove diseased tissues from the ethmoid sinus.
6. A patient undergoes an intranasal ethmoidectomy to remove polyps and improve nasal breathing.
7. A provider performs an ethmoidectomy using an intranasal approach to remove diseased tissues and alleviate symptoms in a patient with ethmoid sinusitis.
8. Using an intranasal approach, a provider excises cells in the ethmoid bone to address nasal obstruction in a patient.
9. A unilateral ethmoidectomy is performed by a provider to remove diseased tissues and improve sinus drainage in a patient.
10. A provider uses an intranasal approach to perform an ethmoidectomy and remove polyps from the ethmoid sinus of a patient with chronic sinusitis.