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Official Description

Lavage by cannulation; sphenoid sinus

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

The procedure described by CPT® Code 31002 refers to the lavage of the sphenoid sinus through cannulation. This medical intervention is primarily performed to address sinus infections, particularly those affecting the sphenoid sinus, which is located deep within the skull, behind the ethmoid sinuses. The sphenoid sinus is one of the paranasal sinuses and plays a role in the respiratory system by helping to humidify and filter the air we breathe. Lavage, in this context, involves the flushing of the sinus with a saline solution to remove infected material, such as pus and mucus, thereby alleviating symptoms associated with sinusitis. The procedure may involve various approaches, including accessing the sphenoid sinus through the maxillary sinus, which requires careful navigation through the anatomical structures of the nasal cavity. The use of a cannula allows for precise delivery of the saline solution, ensuring effective cleansing of the sinus cavity. This procedure is essential for restoring normal sinus function and relieving discomfort caused by sinus infections.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The lavage of the sphenoid sinus, as described by CPT® Code 31002, is indicated for the treatment of conditions that involve infection or inflammation of the sphenoid sinus. The following are specific indications for this procedure:

  • Sinusitis - Inflammation or infection of the sphenoid sinus, often characterized by symptoms such as facial pain, headache, nasal congestion, and purulent nasal discharge.
  • Chronic Sinus Infection - Persistent infection of the sphenoid sinus that does not respond to medical management, necessitating surgical intervention for relief.
  • Obstruction - Blockage of the sphenoid sinus ostium that may lead to accumulation of secretions and subsequent infection.

2. Procedure

The lavage of the sphenoid sinus involves several procedural steps to ensure effective treatment. The following outlines the detailed steps involved in the procedure:

  • Step 1: Anesthesia - The procedure typically begins with the administration of local anesthesia to ensure patient comfort during the lavage process. This may involve the application of anesthetic agents to the nasal mucosa.
  • Step 2: Accessing the Maxillary Sinus - One common approach to reach the sphenoid sinus is through the maxillary sinus. The surgeon may first create an opening in the nasoantral wall, allowing access to the maxillary sinus.
  • Step 3: Cannulation - A cannula is then carefully passed through the newly created opening in the nasoantral wall into the maxillary sinus. The cannula is advanced towards the middle turbinate and subsequently directed to the sphenoid ostium.
  • Step 4: Puncturing the Sphenoid Wall - Once the cannula reaches the sphenoid ostium, the anterior wall of the sphenoid sinus is punctured. This step is critical for allowing the saline solution to enter the sinus cavity.
  • Step 5: Lavage - The final step involves flushing the sphenoid sinus with a saline solution. This process helps to remove infected material, such as pus and mucus, thereby promoting healing and alleviating symptoms associated with the sinus infection.

3. Post-Procedure

After the lavage procedure is completed, patients may be monitored for any immediate complications. Post-procedure care typically includes instructions for nasal hygiene and the use of saline sprays to keep the nasal passages moist. Patients may also be advised to avoid strenuous activities and to follow up with their healthcare provider to assess the effectiveness of the lavage and to monitor for any signs of recurrence of infection. Recovery time may vary depending on the individual and the extent of the procedure performed.

Short Descr IRRIGATION SPHENOID SINUS
Medium Descr LAVAGE CANNULATION SPHENOID SINUS
Long Descr Lavage by cannulation; sphenoid sinus
Status Code Active Code
Global Days 010 - Minor Procedure
PC/TC Indicator (26, TC) 0 - Physician Service Code
Multiple Procedures (51) 2 - Standard payment adjustment rules for multiple procedures apply.
Bilateral Surgery (50) 1 - 150% payment adjustment for bilateral procedures applies.
Physician Supervisions 09 - Concept does not apply.
Assistant Surgeon (80, 82) 0 - Payment restriction for assistants at surgery applies to this procedure...
Co-Surgeons (62) 0 - Co-surgeons not permitted for this procedure.
Team Surgery (66) 0 - Team surgeons not permitted for this procedure.
Diagnostic Imaging Family 99 - Concept Does Not Apply
APC Status Indicator Hospital Part B services paid through a comprehensive APC
ASC Payment Indicator Office-based surgical procedure added to ASC list in CY 2008 or later without MPFS nonfacility PE RVUs; payment based on OPPS relative payment weight.
Type of Service (TOS) 2 - Surgery
Berenson-Eggers TOS (BETOS) P1G - Major procedure - Other
MUE 1
CCS Clinical Classification 32 - Other non-OR therapeutic procedures on nose, mouth and pharynx
50 Bilateral procedure: unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code. note: this modifier should not be appended to designated "add-on" codes (see appendix d).
51 Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d).
54 Surgical care only: when 1 physician or other qualified health care professional performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services may be identified by adding modifier 54 to the usual procedure number.
58 Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78.
59 Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25.
78 Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.)
79 Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.)
GC This service has been performed in part by a resident under the direction of a teaching physician
LT Left side (used to identify procedures performed on the left side of the body)
RT Right side (used to identify procedures performed on the right side of the body)
SG Ambulatory surgical center (asc) facility service
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
XU Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
Date
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2011-01-01 Changed Short description changed.
Pre-1990 Added Code added.
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