How To Use CPT Code 31255

CPT 31255 describes a surgical procedure involving nasal/sinus endoscopy with ethmoidectomy. 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 31255?

CPT 31255 is a code used to describe a surgical procedure called nasal/sinus endoscopy with ethmoidectomy. This procedure involves the removal or excision of cells in the ethmoid bone or ethmoid sinus. It is typically performed when both the anterior and posterior parts of the ethmoid sinus are affected by sinusitis.

2. Official Description

The official description of CPT code 31255 is: ‘Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior).’ It is important to note that this code should not be reported in conjunction with certain other codes that are performed on the same side.

3. Procedure

1. The procedure begins with the administration of anesthesia to the patient.
2. A rigid or flexible endoscope is then inserted into the nasal cavity.
3. The physician uses the endoscope to access the anterior portion of the nasal cavity and identifies the ethmoid bulla.
4. The ethmoid bulla is opened and resected using cutting forceps, providing a clear view of the nasal lamella and retrobulbar space.
5. The anterior cells are opened and removed.
6. The posterior ethmoid is opened, and the bony partition is removed to allow for proper visualization of the ethmoid roof and the creation of a smooth cavity.
7. The posterior artery is identified, and the physician removes any diseased or loose bony partition from the lamella papyracea.
8. Finally, the endoscope is removed from the nasal cavity.

4. Qualifying circumstances

CPT 31255 is typically performed on patients who have sinusitis affecting both the anterior and posterior parts of the ethmoid sinus. It is important to note that this code should not be reported in conjunction with certain other codes that are performed on the same side.

5. When to use CPT code 31255

CPT code 31255 should be used when performing a surgical procedure involving nasal/sinus endoscopy with ethmoidectomy. It is important to ensure that the procedure involves the total removal of cells in both the anterior and posterior parts of the ethmoid sinus. This code should not be used if other specific codes are performed on the same side.

6. Documentation requirements

To support a claim for CPT code 31255, the following documentation is required:

• Patient’s diagnosis and the need for nasal/sinus endoscopy with ethmoidectomy
• Details of the procedure performed, including the specific techniques used
• Date of the procedure
• Start and end time of the procedure
• Any complications or unexpected findings during the procedure
• Signature of the performing physician

7. Billing guidelines

When billing for CPT code 31255, it is important to ensure that the procedure performed meets the criteria for this code. Additionally, this code should not be reported in conjunction with certain other codes that are performed on the same side. It is important to review the specific billing guidelines and requirements of the payer to ensure accurate and appropriate billing.

8. Historical information

CPT code 31255 was added to the Current Procedural Terminology system on January 1, 1990. The code was later updated on January 1, 2018, with a revised description that included the term “total” to clarify the extent of the ethmoidectomy.

9. Examples

1. A patient undergoes nasal/sinus endoscopy with ethmoidectomy to treat chronic sinusitis affecting both the anterior and posterior parts of the ethmoid sinus.
2. A physician performs nasal/sinus endoscopy with ethmoidectomy to remove diseased cells in the ethmoid sinus and improve nasal breathing for a patient with recurrent sinus infections.
3. A surgeon performs nasal/sinus endoscopy with ethmoidectomy to treat a patient with nasal polyps and chronic sinusitis affecting both the anterior and posterior parts of the ethmoid sinus.
4. A patient with a history of sinusitis undergoes nasal/sinus endoscopy with ethmoidectomy to remove diseased cells and improve sinus drainage.
5. A physician performs nasal/sinus endoscopy with ethmoidectomy to treat a patient with ethmoid sinusitis and nasal obstruction.
6. A surgeon performs nasal/sinus endoscopy with ethmoidectomy to remove polyps and diseased cells in the ethmoid sinus for a patient with chronic sinusitis.
7. A patient with chronic sinusitis undergoes nasal/sinus endoscopy with ethmoidectomy to improve sinus drainage and alleviate symptoms.
8. A physician performs nasal/sinus endoscopy with ethmoidectomy to treat a patient with recurrent sinus infections and nasal congestion.
9. A surgeon performs nasal/sinus endoscopy with ethmoidectomy to remove diseased cells and improve sinus ventilation for a patient with chronic sinusitis.
10. A patient with ethmoid sinusitis undergoes nasal/sinus endoscopy with ethmoidectomy to alleviate symptoms and improve sinus drainage.