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A diagnostic nasal endoscopy with sphenoid sinusoscopy involves the use of an endoscope to visually examine the nasal cavity and the sphenoid sinuses, which are located within the sphenoid bone at the back of the nasal cavity. This procedure is essential for identifying any diseases or abnormalities present in these areas. The sphenoid sinuses are paired structures that communicate with the upper posterior nasal cavity, specifically the sphenoethmoidal recess. During the procedure, a topical nasal decongestant may be applied to reduce swelling and improve visibility, while a local anesthetic with a vasoconstrictor is used to minimize discomfort and control bleeding. The endoscope is carefully introduced into the nasal cavity, allowing for a thorough evaluation of the nasal passages and the vomer bone, as well as the face of the sphenoid sinus. Access to the sphenoid sinus can be achieved either by enlarging and cannulating the natural ostium or through a direct puncture of the sphenoidal face, a technique known as sphenoidotomy. This examination may be enhanced by the use of a camera, which allows for real-time visualization on a video monitor, and the ability to record images for further analysis. Overall, this procedure is a critical diagnostic tool in the assessment of sinus-related conditions.
© Copyright 2025 Coding Ahead. All rights reserved.
The diagnostic nasal endoscopy with sphenoid sinusoscopy is indicated for the evaluation of various conditions affecting the nasal cavity and sphenoid sinuses. The following are specific indications for performing this procedure:
The procedure for diagnostic nasal endoscopy with sphenoid sinusoscopy involves several key steps to ensure a thorough examination of the nasal cavity and sphenoid sinuses. The following outlines the procedural steps:
After the completion of the diagnostic nasal endoscopy with sphenoid sinusoscopy, patients may experience some mild discomfort or nasal congestion, which is typically temporary. Post-procedure care may include instructions for nasal hygiene and the use of saline sprays to keep the nasal passages moist. Patients are advised to monitor for any signs of complications, such as increased bleeding or signs of infection, and to follow up with their healthcare provider as necessary. The results of the procedure will be discussed with the patient, and any further treatment options will be considered based on the findings.
| Short Descr | NSL/SINS NDSC DX SPHN SINUSC | Medium Descr | NASAL/SINUS ENDOSCOPY DX SPHENOID SINUSOSCOPY | Long Descr | Nasal/sinus endoscopy, diagnostic; with sphenoid sinusoscopy (via puncture of sphenoidal face or cannulation of ostium) | 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 | 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) | 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). | 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) | 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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