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2025 CPT code 31231

Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure)

This code represents a unilateral or bilateral procedure. It includes dilation of sinus ostia and fluoroscopy if performed.It is not to be reported with other endoscopic sinus surgery procedures performed on the same date. Modifiers 52 and 53 can be applied if the examination is not complete.

Modifiers 22, 47, 51, 52, 53, 58, 59, 73, 74, 76, 77, 78, 79, and 99 are applicable to this code as needed to reflect variations in service or circumstances.

Medical necessity for 31231 must be supported by the patient's presenting symptoms and the clinical indication for the procedure. The documentation should clearly establish the need for the diagnostic endoscopy to evaluate a specific nasal or sinus condition.

The physician prepares the patient, administers a topical anesthetic and/or decongestant, inserts the endoscope, examines the nasal cavity and sinus passages, and documents the findings.

In simple words: A nasal endoscopy is a procedure where a doctor uses a thin, flexible tube with a camera and light to look inside your nose and sinuses. This helps them diagnose various nasal and sinus conditions.

This code represents a diagnostic nasal endoscopy procedure performed unilaterally or bilaterally. It involves inserting an endoscope into the nasal cavity to examine the structures within, including the nasal mucosa, sinus openings, turbinates, and sphenoethmoid recess.It is considered a separate procedure and is not reported when performed as part of a more extensive, related service.

Example 1: A patient presents with chronic nasal congestion and facial pressure. A diagnostic nasal endoscopy (31231) is performed to evaluate for sinusitis, nasal polyps, or other abnormalities., A child has persistent unilateral nasal discharge and a suspected foreign body. A nasal endoscopy (31231) is performed to visualize and potentially remove the foreign body., A patient with a history of epistaxis (nosebleeds) undergoes a nasal endoscopy (31231) to identify the source of bleeding.

Documentation should include the reason for the endoscopy, findings (including the areas examined and any abnormalities identified), and any procedures performed (e.g., biopsy, foreign body removal).If the exam is limited, the reason for the limitation and the use of modifiers (52 or 53) should also be documented.

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