How To Use CPT Code 31231

CPT 31231 refers to a diagnostic nasal endoscopy procedure performed on one or both sides of the nasal cavity. This article will cover topics such as the description, procedure, qualifying circumstances, when to use the code, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 31231 procedures.

1. What is CPT 31231?

CPT 31231 is a medical code used to describe a diagnostic nasal endoscopy procedure. This procedure involves the insertion of an endoscope into the nasal cavity to examine the structures of the nasal cavity on one or both sides. It is a separate procedure and should not be reported separately when performed as part of a larger, related service.

2. 31231 CPT code description

The official description of CPT code 31231 is: “Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure)”.

3. Procedure

The 31231 procedure involves the following steps:

1. The patient is appropriately prepped and anesthetized.
2. The provider inserts a rigid or flexible endoscope into the nasal cavity.
3. The endoscope is extended along the floor of the nasal cavity into the nasopharynx.
4. The provider examines the entire nasopharynx.
5. The endoscope is passed between the middle and inferior turbinates.
6. The provider repositions the head of the endoscope to an angle and advances it into the olfactory cleft to look for any polyps.
7. The endoscope is carefully removed.

The procedure can be performed on one or both sides of the nasal cavity and does not require any incision.

4. Qualifying circumstances

Patients who are eligible to receive CPT code 31231 services are those experiencing symptoms or conditions that warrant a diagnostic nasal endoscopy. These may include:

• Nasal obstruction or congestion
• Chronic sinusitis
• Nasal polyps
• Epistaxis (nosebleeds)
• Postnasal drip
• Facial pain or pressure
• Headaches
• Loss of smell or taste
• Snoring or sleep apnea
• Suspected tumors or masses

5. When to use CPT code 31231

It is appropriate to bill the 31231 CPT code when a diagnostic nasal endoscopy is performed as a separate procedure to evaluate the patient’s symptoms or conditions listed in the qualifying circumstances section. The code should not be reported separately when the provider performs the endoscopy as part of a larger, related service.

6. Documentation requirements

To support a claim for CPT 31231, the following information should be documented:

• Patient’s medical history and presenting symptoms or conditions
• Physical examination findings
• Indication for the diagnostic nasal endoscopy
• Details of the procedure, including the type of endoscope used, side(s) examined, and any abnormalities or findings observed
• Post-procedure care instructions and follow-up plan

7. Billing guidelines

When billing for CPT code 31231, it is important to follow these guidelines:

• Ensure that the procedure is performed as a separate service and not as part of a larger, related service.
• Verify that the patient’s symptoms or conditions warrant the use of a diagnostic nasal endoscopy.
• Document all necessary information to support the claim, as outlined in the documentation requirements section.
• Be aware of any payer-specific rules or guidelines that may apply to the billing of CPT 31231.

8. Historical information

CPT 31231 was added to the Current Procedural Terminology system on January 1, 1994. There have been no updates to the code since its addition.

9. Similar codes to CPT 31231

Five similar codes to CPT 31231 and how they differentiate are:

• CPT 31233: Nasal/sinus endoscopy, diagnostic with maxillary sinusotomy (includes removal of polyps, if present); unilateral – This code includes a maxillary sinusotomy and is performed unilaterally.
• CPT 31235: Nasal/sinus endoscopy, surgical with ethmoidectomy; unilateral – This code involves a surgical endoscopy with ethmoidectomy and is performed unilaterally.
• CPT 31237: Nasal/sinus endoscopy, surgical with polypectomy – This code is for a surgical endoscopy with polypectomy.
• CPT 31238: Nasal/sinus endoscopy, surgical with control of nasal hemorrhage – This code is for a surgical endoscopy with control of nasal hemorrhage.
• CPT 31239: Nasal/sinus endoscopy, surgical with sphenoidotomy; unilateral – This code involves a surgical endoscopy with sphenoidotomy and is performed unilaterally.

10. Examples

Here are 10 detailed examples of CPT code 31231 procedures:

1. A patient presents with chronic sinusitis and nasal congestion. The provider performs a diagnostic nasal endoscopy on both sides to evaluate the patient’s condition.
2. A patient with a history of nasal polyps undergoes a diagnostic nasal endoscopy to check for the presence of new polyps.
3. A patient experiences recurrent nosebleeds. The provider performs a diagnostic nasal endoscopy to identify the source of the bleeding.
4. A patient complains of facial pain and pressure. The provider performs a diagnostic nasal endoscopy to rule out sinusitis or other nasal abnormalities.
5. A patient with suspected sleep apnea undergoes a diagnostic nasal endoscopy to evaluate the nasal airway for obstruction.
6. A patient presents with a loss of smell and taste. The provider performs a diagnostic nasal endoscopy to examine the olfactory cleft for any abnormalities.
7. A patient complains of headaches and postnasal drip. The provider performs a diagnostic nasal endoscopy to evaluate the patient’s nasal and sinus structures.
8. A patient with a history of snoring undergoes a diagnostic nasal endoscopy to assess the nasal airway for any obstructions or abnormalities.
9. A patient presents with a suspected nasal tumor. The provider performs a diagnostic nasal endoscopy to examine the nasal cavity for any masses or growths.
10. A patient complains of chronic nasal congestion and facial pain. The provider performs a diagnostic nasal endoscopy on both sides to evaluate the patient’s nasal and sinus structures.