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2025 CPT code 31075

Transorbital, unilateral sinusotomy of the frontal sinus for removal of mucocele or osteoma (Lynch type).

Follow current CPT coding guidelines for surgical procedures.Proper documentation is crucial for accurate coding.

Modifiers 50 (bilateral procedure), RT (right side), LT (left side), and others may be applicable depending on the specific circumstances of the procedure and payer requirements.

The procedure is medically necessary when a frontal sinus mucocele or osteoma causes symptoms (e.g., pain, pressure, visual impairment) that significantly impact the patient's quality of life and cannot be managed conservatively.Documentation of the symptoms and the failure of less invasive treatments should support the medical necessity.

The otolaryngologist (ENT surgeon) or neurosurgeon is typically responsible for performing this procedure.The surgeon's responsibilities include patient preparation, anesthesia administration (if applicable), incision, access to the frontal sinus, removal of the diseased tissue, and wound closure. Postoperative care may be shared with other healthcare professionals.

IMPORTANT If the procedure is performed bilaterally, append modifier 50.Alternatively, use modifiers RT (right) or LT (left) depending on payer preferences.

In simple words: The doctor makes a cut near the inner corner of the eye to reach the frontal sinus (air space in the forehead).They remove a cyst or benign growth from the sinus and close the cut.

This procedure involves a unilateral transorbital approach to the frontal sinus.An incision is made along the inner wall of the orbit, extending to the area above the eye socket. An opening is created into the ethmoid sinus to access the frontal sinus. Diseased tissue, such as a mucocele (mucus retention cyst) or osteoma (benign bone tumor), is removed from the frontal sinus using appropriate instruments like curettes. The wound is then closed in layers.

Example 1: A 45-year-old patient presents with a large mucocele in the right frontal sinus, causing significant pain and pressure.A transorbital approach is chosen due to the size and location of the mucocele.The surgeon performs a right-sided 31075., A 60-year-old patient has an osteoma in their left frontal sinus that is causing pressure on the eye and affecting vision.The surgeon performs a left-sided 31075 to remove the osteoma. Modifier LT may be appended., A patient presents with bilateral frontal sinus mucoceles.The surgeon performs a bilateral procedure (requiring two separate incisions), and modifier 50 is appended to code 31075 to indicate bilateral service.

* Preoperative diagnosis (e.g., mucocele, osteoma) with imaging studies (CT scan, MRI) to confirm the location and size of the lesion.* Operative report detailing the surgical approach (transorbital), the extent of the procedure, the type of tissue removed, and the surgical findings.* Anesthesia records if anesthesia was administered.* Postoperative recovery notes.* Pathology report confirming the diagnosis of the removed tissue.

** This procedure is relatively complex and requires specialized surgical skills and equipment.Proper documentation is paramount for accurate coding and reimbursement.

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