Wiki What needs to be done for 31231?

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lindsayroper

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The CPT codebook states 31231 "inspects the interior of the nasal cavity and the middle and superior meatus, the turbinates and the spheno-ethmoid recess."
Do all these structures need to be documented in the chart note in order to use 31231? What if the Dr scoped the turbinates and the superior meatus, but didn't document he looked at the middle meatus or the spheno-ethmoid recess? Can 31231 still be used?
 
If the doctor CAN view only those areas with a nasal speculum and not have to use the sinus endoscope, then it would not be appropriate to use the nasal endoscopy.

most MAC's have Guidelines and LCD's on CPT code 31231. here is an excerpt.

A diagnostic nasal endoscopic examination permits visualization of upper airway structures inaccessible to the conventional otoscope or nasal speculum. The endoscopic examination is a safe and rapid (10-15 minutes) procedure used to diagnose nasal and/or sinus pathologic conditions and is performed with a rigid nasal endoscope and/or a flexible endoscope. A nasopharynx examination inspects the posterior naspharyngeal wall, posterior choanae, fossa of Rosenmueller, eustachian tube orifices, and the superior aspect of the soft palate. The nasal/sinus examination involves the inspection of the above mentioned areas in addition to the spheno-ethnoidal recess.
 
Thanks for the reply, but that doesn't answer my question.
I don't need to know the indications for the use of a scope. I need to know what anatomical structures need to be documented/visualized in order for the scope itself to be billed.
For example, if the Dr documents that he uses the scope to look at the middle meatus (and nothing else) - is this what qualifies for the use of the scope? OR does the Dr have to document/visualize the middle meatus, turbinates, nasal cavity, spheno-eth recess (all the structures listed in the CPT book for this code) in order for the 31231 to be properly billed?
 
Position Statement from the American Rhinological Association: If this does not help you then I apologize.


Diagnostic nasal endoscopy is a procedure performed to better characterize the anatomy of the nasal cavity and/or paranasal sinuses and to identify sinonasal pathology not afforded by anterior rhinoscopy. It is typically performed in the office setting using rigid or flexible endoscopes, often, but not always with topical decongestion and/or anesthesia, though can be performed in the operating room as well. Many practitioners often also utilize a video monitor and a recording device for documentation and education purposes.

Common indications for diagnostic nasal endoscopy include but are not limited to:

  • Evaluate for chronic sinonasal symptoms unexplained by anterior rhinoscopy
  • Assess interval response to medical or surgical therapy in patients with chronic sinusitis and recurrent acute sinusitis
  • Monitor for recurrence of nasal polyps
  • Evaluate and manage epistaxis
  • Perform endoscopically guided cultures
  • Assess facial pain suggestive of rhinogenic origin
  • Evaluate clear rhinorrhea suggestive of cerebrospinal fluid leak
  • Perform initial diagnosis and interval surveillance for sinonasal neoplasms
 
Last edited:
lindsayroper said:
The CPT codebook states 31231 "inspects the interior of the nasal cavity and the middle and superior meatus, the turbinates and the spheno-ethmoid recess."
Do all these structures need to be documented in the chart note in order to use 31231? What if the Dr scoped the turbinates and the superior meatus, but didn't document he looked at the middle meatus or the spheno-ethmoid recess? Can 31231 still be used?
Click to expand...
Yes they all should be documented. Append Modifier 52 when note does not include all
 
Has anyone been told by their ENT providers that the superior meatus can not be visualized? We are having that issue, so ALL our 31231's are going out with the 52 modifier.
If that is true, why is it a requirement?
 
Candice_Fenildo said:
Position Statement from the American Rhinological Association: If this does not help you then I apologize.


Diagnostic nasal endoscopy is a procedure performed to better characterize the anatomy of the nasal cavity and/or paranasal sinuses and to identify sinonasal pathology not afforded by anterior rhinoscopy. It is typically performed in the office setting using rigid or flexible endoscopes, often, but not always with topical decongestion and/or anesthesia, though can be performed in the operating room as well. Many practitioners often also utilize a video monitor and a recording device for documentation and education purposes.

Common indications for diagnostic nasal endoscopy include but are not limited to:

  • Evaluate for chronic sinonasal symptoms unexplained by anterior rhinoscopy
  • Assess interval response to medical or surgical therapy in patients with chronic sinusitis and recurrent acute sinusitis
  • Monitor for recurrence of nasal polyps
  • Evaluate and manage epistaxis
  • Perform endoscopically guided cultures
  • Assess facial pain suggestive of rhinogenic origin
  • Evaluate clear rhinorrhea suggestive of cerebrospinal fluid leak
  • Perform initial diagnosis and interval surveillance for sinonasal neoplasms
Click to expand...
Hi, this is the CPT Asst. take:

Introductory Text Key Changes
The introductory text was expanded to further define the components of a diagnostic nasal endoscopy. A complete diagnostic nasal endoscopy (31231) includes visualization of the nasal cavity interior, the middle and superior meatus, the turbinates, and the spheno-ethmoid recess. If any of these structures cannot be visualized (eg, due to anatomic considerations, patient factors), append modifier 52, Reduced services, to code 31231.

I am auditing ENT and the provider is billing 31575 Laryngoscopy, flexible; diagnostic.
Note below:
After written consent and topical anesthesia with lidocaine and afrin a flexible endoscope was passed through the nasal airway without difficulty. The following structures were examined bilaterally unless otherwise indicated below: Nasal mucosa, inferior and middle turbinates, septum, middle meatus, nasopharynx. Findings detailed below. The patient tolerated the procedure well.
FINDINGS: No obvious mucopus or polyps no masses or lesions. Open max antrostomy on the left with accessory ostia posteriorly. No evidence of sinus disease in the necks or sinus. On the right take nasal cavity unable to pass scope to see maxillary antrostomy.

My thoughts are to advise the provider to change from 31575 to 31231 with the 52 modifier in future.

Your thoughts are greatly appreciated.
 
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