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An intranasal ethmoidectomy, specifically coded as CPT® 31201, is a surgical procedure aimed at removing diseased tissue from both the anterior and posterior ethmoid cells located within the nasal cavity. This procedure is typically indicated for patients suffering from chronic sinusitis or other conditions that lead to inflammation and blockage of the ethmoid sinuses. The surgery begins with the application of topical vasoconstrictive agents to minimize bleeding and the injection of a local anesthetic to ensure patient comfort during the procedure. The middle turbinate, a structure within the nasal cavity, is gently moved forward to provide access to the sinus ostium, which is the opening to the ethmoid sinuses. A curette, a surgical instrument designed for scraping or removing tissue, is then inserted through this opening to excise inflamed and diseased tissue. In contrast to the procedure coded as CPT® 31200, which focuses solely on the anterior ethmoid cells, CPT® 31201 encompasses a total ethmoidectomy, involving comprehensive removal of all mucosal tissue from both the anterior and posterior ethmoid cells down to the underlying bone. This thorough approach aims to alleviate symptoms and restore normal sinus function by addressing the source of inflammation and blockage within the ethmoid sinuses.
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The intranasal total ethmoidectomy (CPT® 31201) is indicated for patients experiencing conditions that lead to significant inflammation and obstruction of the ethmoid sinuses. These indications may include:
The procedure for a total ethmoidectomy (CPT® 31201) involves several critical steps to ensure the effective removal of diseased tissue from both the anterior and posterior ethmoid cells. The following procedural steps are performed:
After the total ethmoidectomy, patients may experience some discomfort and nasal congestion as part of the recovery process. Post-procedure care typically includes instructions for managing pain, such as the use of prescribed analgesics, and recommendations for nasal saline irrigation to promote healing and clear any residual mucus. Follow-up appointments are essential to monitor the healing process and ensure that the sinuses are functioning properly. Patients should be advised to avoid strenuous activities and to report any signs of complications, such as excessive bleeding or signs of infection, to their healthcare provider promptly.
| Short Descr | REMOVAL OF ETHMOID SINUS | Medium Descr | ETHMOIDECTOMY INTRANASAL TOTAL | Long Descr | Ethmoidectomy; intranasal, total | Status Code | Active Code | Global Days | 090 - Major Surgery | 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) | 1 - Statutory 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 | Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P5E - Ambulatory procedures - other | MUE | 1 | CCS Clinical Classification | 33 - Other 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). | 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. | 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) |
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| Pre-1990 | Added | Code added. |
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