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A diagnostic nasal endoscopy with maxillary sinusoscopy via inferior meatus or canine fossa puncture is a procedure that allows for the examination of the nasal cavity and the maxillary sinuses. The maxillary sinuses, which are the largest of the paranasal sinuses, are situated on either side of the nose within the body of the maxilla, the upper jawbone. The inferior meatus is one of the four main passages in the nasal cavity, located just beneath the inferior concha, which is a bony structure that helps to filter and humidify the air we breathe. The canine fossa, on the other hand, is a specific anatomical area characterized by a depression at the front of the maxilla, positioned below the infraorbital opening and adjacent to the canine tooth socket. During this procedure, a topical nasal decongestant may be applied to reduce swelling and facilitate easier access to the nasal passages. Additionally, a local anesthetic combined with a vasoconstrictor may be utilized to minimize discomfort and control bleeding. The procedure involves puncturing the inferior meatus of the nasal cavity or inserting a trocar through the anterior face of the maxilla at the canine fossa. Once access is achieved, an endoscope is introduced, allowing the physician to visually inspect the nasal cavity and the maxillary sinus for any signs of disease or abnormalities. This endoscopic examination can be enhanced by the use of a camera, which captures images that can be displayed on a video monitor, recorded on a VCR, or saved digitally for further analysis and documentation.
© Copyright 2025 Coding Ahead. All rights reserved.
The diagnostic nasal endoscopy with maxillary sinusoscopy is indicated for various conditions affecting the nasal cavity and maxillary sinuses. The following are the explicitly provided indications for this procedure:
The procedure involves several key steps to ensure a thorough examination of the nasal cavity and maxillary sinuses. The following procedural steps are outlined:
After the completion of the diagnostic nasal endoscopy with maxillary sinusoscopy, the patient may be monitored for any immediate complications. It is common for patients to experience some nasal discomfort or minor bleeding following the procedure. Instructions for post-procedure care typically include recommendations for avoiding strenuous activities and managing any discomfort with over-the-counter pain relief as needed. Patients may also be advised to avoid blowing their nose for a specified period to prevent any disruption to the healing process. Follow-up appointments may be scheduled to discuss findings and any further treatment options if necessary.
| Short Descr | NSL/SINS NDSC DX MAX SINUSC | Medium Descr | NASAL/SINUS ENDOSCOPY DX MAXILLARY SINUSOSCOPY | Long Descr | Nasal/sinus endoscopy, diagnostic; with maxillary sinusoscopy (via inferior meatus or canine fossa puncture) | Status Code | Active Code | Global Days | 000 - Endoscopic or Minor Procedure | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 3 - Special payment adjustment rules for multiple endoscopic 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. | Endoscopic Base Code | 31231 Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure) | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Procedure or Service, Multiple Reduction Applies | 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) | P8I - Endoscopy - other | MUE | 1 | CCS Clinical Classification | 31 - Diagnostic 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). | LT | Left side (used to identify procedures performed on the left side of the body) | 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. | RT | Right side (used to identify procedures performed on the right side of the body) | 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.) | 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). | 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 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.) | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | GA | Waiver of liability statement issued as required by payer policy, individual case | GC | This service has been performed in part by a resident under the direction of a teaching physician | GV | Attending physician not employed or paid under arrangement by the patient's hospice provider | GW | Service not related to the hospice patient's terminal condition | 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 |
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| 2020-01-01 | Changed | Code description changed. |
| 2011-01-01 | Changed | Short description changed. Guideline information changed. |
| 1994-01-01 | Added | First appearance in code book in 1994. |
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