How To Use CPT Code 31230

CPT 31230 describes the surgical procedure known as maxillectomy with orbital exenteration. This article will cover the description, official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 31230?

CPT 31230 is a code used to describe a surgical procedure called maxillectomy with orbital exenteration. This procedure involves the removal of the upper jaw (maxilla) and the contents of the eye’s orbit as a single unit.

2. Official Description

The official description of CPT code 31230 is: ‘Maxillectomy; with orbital exenteration (en bloc).’ This code should not be used for orbital exenteration alone, as there are separate codes for that procedure (65110 et seq). Skin grafts also have their own specific codes (15120 et seq).

3. Procedure

1. The surgeon begins the procedure by making a Weber Ferguson incision, which extends to the upper eyelid and may involve the orbit.
2. The maxilla is fractured, and a flap is elevated from the anterior wall of the maxilla, extending to the maxillary tuberosity.
3. The diseased tissues, such as a tumor, are removed from the maxilla.
4. An incision is made in the superior orbit to gain access to the nerves and vessels of the orbit.
5. The diseased contents of the eye’s orbit are removed.
6. The extracted tissues are sent to pathology for further analysis.
7. A split-thickness skin graft may be applied, and drains are inserted.
8. The incisions are closed in layers, and a splint may be placed to protect the site of incision.

4. Qualifying circumstances

CPT 31230 is performed on patients who require the removal of the maxilla and the contents of the eye’s orbit as a single unit. This procedure is typically performed to treat conditions such as tumors or other diseases affecting these areas. It is important to note that this code should not be used for orbital exenteration alone or for skin grafts.

5. When to use CPT code 31230

CPT code 31230 should be used when a surgeon performs a maxillectomy with orbital exenteration. It should not be used for orbital exenteration alone or for skin grafts. It is important to accurately document the specific procedure performed to ensure proper coding.

6. Documentation requirements

To support a claim for CPT code 31230, the surgeon must document the following information:

• Patient’s diagnosis and the need for maxillectomy with orbital exenteration
• Details of the procedure performed, including the specific incisions made and tissues removed
• Date of the procedure
• Any additional procedures or techniques used during the surgery
• Any complications or unexpected findings
• Signature of the surgeon performing the procedure

7. Billing guidelines

When billing for CPT code 31230, ensure that the procedure performed meets the criteria for maxillectomy with orbital exenteration. It is important to accurately document the details of the procedure and any additional techniques used. If other procedures, such as skin grafts, are performed in conjunction with CPT 31230, separate codes should be used to report those services.

8. Historical information

CPT code 31230 was added to the Current Procedural Terminology system on January 1, 1990. The code has not undergone any updates since its addition. In 2017, it was added to the Inpatient Only (IPO) list for Medicare billing purposes.

9. Examples

1. A surgeon performs a maxillectomy with orbital exenteration to remove a tumor from a patient’s upper jaw and eye’s orbit.
2. During a surgical procedure, a maxillectomy with orbital exenteration is performed to treat a patient with a rare disease affecting these areas.
3. A patient undergoes a maxillectomy with orbital exenteration to address a severe trauma to the upper jaw and eye’s orbit.
4. A surgeon performs a maxillectomy with orbital exenteration to remove a malignant tumor from a patient’s maxilla and eye’s orbit.
5. During a complex surgical procedure, a maxillectomy with orbital exenteration is performed to address a recurring disease in the upper jaw and eye’s orbit.
6. A patient with a rare genetic condition undergoes a maxillectomy with orbital exenteration to improve their quality of life and manage their symptoms.
7. A surgeon performs a maxillectomy with orbital exenteration to remove a large tumor that is causing significant pain and discomfort for the patient.
8. During a surgical procedure, a maxillectomy with orbital exenteration is performed to address a life-threatening condition affecting the upper jaw and eye’s orbit.
9. A patient with a history of recurrent tumors undergoes a maxillectomy with orbital exenteration to prevent further spread of the disease.
10. A surgeon performs a maxillectomy with orbital exenteration to address a complex case involving multiple diseases affecting the upper jaw and eye’s orbit.