How To Use CPT Code 31238

CPT 31238 describes a surgical procedure involving the use of an endoscope to control nasal hemorrhage. This article will cover the official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 31238?

CPT 31238 is a code used to describe a surgical procedure in which a provider inserts an endoscope into the nasal cavity to control nasal hemorrhage. The provider uses methods such as bipolar cautery or other means to cauterize or burn the feeding vessels and prevent excessive bleeding. This procedure is performed unilaterally, meaning it is done on one side of the nose.

2. Official Description

The official description of CPT code 31238 is: ‘Nasal/sinus endoscopy, surgical; with control of nasal hemorrhage.’ This code should not be reported in conjunction with codes 31237 or 31241 when performed on the same side.

3. Procedure

1. The provider prepares the patient and administers anesthesia.
2. An endoscope is inserted into the nasal cavity to examine the entire nasal cavity for areas of bleeding.
3. The provider uses methods such as bipolar cautery or other means to control bleeding by cauterizing or burning the feeding vessels.
4. The provider withdraws the endoscope and applies antibiotics to the site to prevent further bleeding.

4. Qualifying circumstances

CPT 31238 is performed on patients who experience nasal hemorrhage and require intervention to control the bleeding. The procedure is typically performed by a provider who is trained in nasal/sinus endoscopy and has the necessary equipment and expertise to perform the procedure safely and effectively.

5. When to use CPT code 31238

CPT code 31238 should be used when a provider performs a surgical procedure to control nasal hemorrhage using an endoscope. This code is appropriate when the procedure is performed unilaterally, meaning it is done on one side of the nose. It should not be reported in conjunction with codes 31237 or 31241 when performed on the same side.

6. Documentation requirements

To support a claim for CPT code 31238, the provider must document the following information:

• Patient’s diagnosis indicating the need for the procedure
• Details of the procedure performed, including the use of an endoscope and the specific methods used to control bleeding
• Date of the procedure
• Any complications or additional interventions required
• Signature of the performing provider

7. Billing guidelines

When billing for CPT code 31238, ensure that the procedure is performed unilaterally and that it is not reported in conjunction with codes 31237 or 31241 when performed on the same side. Modifier 50 should be appended if the procedure is performed bilaterally, or modifiers RT/LT can be used based on payer preference. It is important to follow payer-specific guidelines for reporting and billing this procedure.

8. Historical information

CPT code 31238 was added to the Current Procedural Terminology system on January 1, 1994. There have been no updates or changes to the code since its addition.

9. Examples

1. A provider performs CPT code 31238 to control nasal hemorrhage in a patient who experienced excessive bleeding following a nasal injury.
2. During a surgical procedure, a provider uses CPT code 31238 to cauterize feeding vessels and control nasal hemorrhage in a patient with a history of recurrent nosebleeds.
3. A provider performs CPT code 31238 to control nasal hemorrhage in a patient with a nasal tumor.
4. Following a traumatic accident, a provider uses CPT code 31238 to control nasal hemorrhage in a patient with a fractured nose.
5. A provider performs CPT code 31238 to control nasal hemorrhage in a patient with a bleeding disorder.
6. During a surgical procedure, a provider uses CPT code 31238 to cauterize feeding vessels and control nasal hemorrhage in a patient undergoing sinus surgery.
7. A provider performs CPT code 31238 to control nasal hemorrhage in a patient with chronic sinusitis.
8. Following a nasal trauma, a provider uses CPT code 31238 to control nasal hemorrhage in a patient with a deviated septum.
9. A provider performs CPT code 31238 to control nasal hemorrhage in a patient with nasal polyps.
10. During a surgical procedure, a provider uses CPT code 31238 to cauterize feeding vessels and control nasal hemorrhage in a patient with a nasal foreign body.