How To Use CPT Code 31253

CPT 31253 describes a surgical procedure involving the complete excision of the ethmoid air cells, including the frontal sinus exploration and removal of tissue from the frontal sinus if necessary. 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 31253?

CPT 31253 is a code used to describe a surgical procedure that involves the removal of tissue from the ethmoid air cells, including exploration of the frontal sinus. This procedure is typically performed to treat chronic sinusitis. It is important to note that CPT 31253 should not be reported in conjunction with certain other codes, such as 31237, 31254, or 31255, when performed on the same side.

2. Official Description

The official description of CPT code 31253 is: ‘Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including frontal sinus exploration, with removal of tissue from frontal sinus, when performed.’

3. Procedure

1. The provider begins by preparing the patient and administering anesthesia.
2. A rigid or flexible endoscope is then inserted into the nasal cavity to provide visualization.
3. The provider uses the endoscope to enter the anterior portion of the nasal cavity and resects the uncinate process, which is a hooklike extension of the ethmoid bone.
4. The maxillary antrum is widened, and the provider identifies, opens, and resects the ethmoid bulla to gain a clear view of the nasal lamellae and retrobulbar space.
5. The anterior ethmoid air cells are opened and removed using forceps and a shaver.
6. The provider then opens the posterior ethmoid and removes the bony partition, allowing for a smooth cavity and visualization of the ethmoid roof.
7. If necessary, the provider performs exploration of the frontal sinus and removes any diseased tissue.
8. Throughout the procedure, the provider takes care to avoid a cerebrospinal fluid (CSF) leak and retrobulbar herniation.
9. Finally, the provider removes the instruments from the nasal cavity and packs it with epinephrine-soaked cotton balls.

4. Qualifying circumstances

CPT 31253 is typically performed on patients with chronic sinusitis who require surgical intervention. The procedure involves the complete excision of the ethmoid air cells, including exploration of the frontal sinus and removal of tissue if necessary. It is important to note that CPT 31253 should not be reported in conjunction with certain other codes when performed on the same side.

5. When to use CPT code 31253

CPT code 31253 should be used when a provider performs a surgical procedure involving the complete excision of the ethmoid air cells, including exploration of the frontal sinus and removal of tissue if necessary. It is important to ensure that the procedure is not performed on the same side as certain other codes, as mentioned in the notes for CPT 31253.

6. Documentation requirements

To support a claim for CPT 31253, the provider must document the following information:

• Patient’s diagnosis of chronic sinusitis
• Details of the procedure performed, including the complete excision of the ethmoid air cells, exploration of the frontal sinus, and removal of tissue if necessary
• Date of the procedure
• Any complications or adverse events encountered during the procedure
• Signature of the performing provider

7. Billing guidelines

When billing for CPT 31253, it is important to ensure that the procedure is not performed on the same side as certain other codes, as mentioned in the notes for CPT 31253. It is also important to follow any specific guidelines provided by the payer regarding documentation and coding for this procedure.

8. Historical information

CPT 31253 was added to the Current Procedural Terminology system on January 1, 2018. There have been no updates to the code since its addition.

9. Examples

1. A patient with chronic sinusitis undergoes a surgical procedure involving the complete excision of the ethmoid air cells, exploration of the frontal sinus, and removal of tissue if necessary.
2. A provider performs a nasal/sinus endoscopy with ethmoidectomy, including frontal sinus exploration and removal of tissue from the frontal sinus, on a patient with chronic sinusitis.
3. During a surgical procedure, a provider performs a total ethmoidectomy, including exploration of the frontal sinus and removal of tissue if necessary, to treat chronic sinusitis in a patient.
4. A patient with chronic sinusitis undergoes a surgical procedure involving the complete excision of the ethmoid air cells, exploration of the frontal sinus, and removal of tissue from the frontal sinus if necessary.
5. A provider performs a nasal/sinus endoscopy with ethmoidectomy, including frontal sinus exploration and removal of tissue from the frontal sinus, on a patient with chronic sinusitis.
6. During a surgical procedure, a provider performs a total ethmoidectomy, including exploration of the frontal sinus and removal of tissue if necessary, to treat chronic sinusitis in a patient.
7. A patient with chronic sinusitis undergoes a surgical procedure involving the complete excision of the ethmoid air cells, exploration of the frontal sinus, and removal of tissue if necessary.
8. A provider performs a nasal/sinus endoscopy with ethmoidectomy, including frontal sinus exploration and removal of tissue from the frontal sinus, on a patient with chronic sinusitis.