September 16, 2021

Question:
One of our doctors saw a patient and billed 31231 (nasal endoscopy). The doctor did not document that a topical vasoconstrictive agent was applied.  Does the topical anesthesia need to be applied to bill 31231? If topical anesthesia is required and was not used, would modifier 52 (reduced services) need to be appended to 31231?

Answer:
While topical anesthesia is included in all surgical CPT codes, and not separately billed by the surgeon, there is no requirement that a topical anesthetic must be used. Therefore, modifier 52 is not necessary.

*This response is based on the best information available as of 9/16/21.