Summary & Overview
CPT 31237: Surgical Nasal/Sinus Endoscopy with Biopsy, Polypectomy, or Debridement
CPT code 31237 is a widely utilized billing code in otolaryngology, representing surgical nasal or sinus endoscopy with biopsy, polypectomy, or debridement. This procedure is essential for diagnosing and treating a range of nasal and sinus disorders, including polyps, chronic and acute sinusitis, and structural abnormalities. The code is recognized by major national payers, including Aetna, Blue Cross Blue Shield, Cigna Health, Medicare, and UnitedHealthcare, ensuring broad coverage across commercial and government insurance plans.
This publication provides a comprehensive overview of 31237, detailing its clinical context, typical sites of service, and its role in the management of sinus disease. Readers will gain insights into payer coverage, relevant policy updates, and benchmarks for utilization. The analysis also highlights associated modifiers, taxonomies, and related CPT codes, offering a clear understanding of how this procedure fits within broader otolaryngology billing and coding practices. The information is designed to support stakeholders in navigating reimbursement, compliance, and clinical documentation for surgical endoscopy procedures.
CPT Code Overview
CPT code 31237 represents a surgical nasal or sinus endoscopy procedure performed by an otolaryngologist. This procedure involves the use of an endoscope to examine the nasal cavity and accessory sinuses, with the potential for biopsy, polypectomy, or debridement as a separate procedure. It is commonly performed in an office or outpatient facility setting, such as place of service 11 or 22. This code is integral to the management of various nasal and sinus conditions, providing both diagnostic and therapeutic benefits in otolaryngology practice.
Clinical & Coding Specifications
Clinical Context
A patient presents to an otolaryngology (ENT) clinic with symptoms such as nasal congestion, facial pain, or recurrent sinus infections. The provider suspects conditions like nasal polyps, chronic or acute sinusitis, or structural abnormalities such as a deviated septum. After clinical evaluation, the provider determines that a surgical nasal/sinus endoscopy is necessary. During the procedure, the provider uses an endoscope to visualize the nasal cavity and sinuses, and performs a biopsy, polypectomy, or debridement as indicated. This is typically performed in an office or outpatient facility setting. The procedure is documented under CPT code 31237 for surgical endoscopy with biopsy, polypectomy, or debridement.
Coding Specifications
Common Modifiers:
| Modifier Code | Description | When Used |
|---|---|---|
50 | Bilateral procedure | When the procedure is performed on both sides of the nose/sinuses. |
79 | Unrelated procedure or service by the same physician during the postoperative period | When the procedure is unrelated to a previous surgery and occurs during the postoperative period. |
59 | Distinct procedural service | When the procedure is performed separately from other procedures, indicating it is not bundled. |
22 | Increased procedural services (unusual procedural services) | When the procedure is more complex or extensive than usual. |
52 | Reduced services | When the procedure is partially completed or less extensive than described. |
Associated Provider Taxonomies:
207Y00000X– Otolaryngology Physician207YX0602X– Otolaryngology/Facial Plastic Surgery207YS0123X– Otolaryngology/Plastic Surgery within the Head & Neck
These taxonomies represent providers specializing in ear, nose, and throat disorders, facial plastic surgery, and head & neck plastic surgery.
Related Diagnoses
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J33.0– Polyp of nasal cavity- Relevant when nasal polyps are visualized and removed during endoscopy.
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J32.9– Chronic sinusitis, unspecified- Indicates chronic inflammation of the sinuses, often requiring debridement or biopsy.
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J34.2– Deviated nasal septum- Structural abnormality that may necessitate endoscopic evaluation and intervention.
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J01.90– Acute sinusitis, unspecified- Acute infection or inflammation of the sinuses, may require biopsy or debridement.
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J34.89– Other specified disorders of nose and nasal sinuses- Used for other nasal or sinus conditions not specifically listed, justifying endoscopic procedures.
Related CPT Codes
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31238– Nasal/sinus endoscopy, surgical; with control of nasal hemorrhage- Used when endoscopy is performed to control bleeding, often in acute epistaxis cases. May be performed in conjunction with or as an alternative to
31237if hemorrhage is present.
- Used when endoscopy is performed to control bleeding, often in acute epistaxis cases. May be performed in conjunction with or as an alternative to
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31254– Nasal/sinus endoscopy, surgical; with ethmoidectomy, partial (anterior)- Involves removal of part of the ethmoid sinus. May be performed alongside
31237if polypectomy or debridement is needed in the ethmoid region.
- Involves removal of part of the ethmoid sinus. May be performed alongside
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31255– Nasal/sinus endoscopy, surgical; with ethmoidectomy, total (anterior and posterior)- More extensive ethmoid sinus surgery. Used when disease involves both anterior and posterior ethmoid sinuses.
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31256– Nasal/sinus endoscopy, surgical; with maxillary antrostomy- Creation of an opening in the maxillary sinus. May be performed with
31237if tissue removal or debridement is needed in the maxillary sinus.
- Creation of an opening in the maxillary sinus. May be performed with
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31267– Nasal/sinus endoscopy, surgical; with removal of tissue from maxillary sinus- Removal of diseased tissue from the maxillary sinus. Can be used with or instead of
31237depending on the location and extent of disease.
- Removal of diseased tissue from the maxillary sinus. Can be used with or instead of
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31276– Nasal/sinus endoscopy, surgical; with frontal sinus exploration, with or without removal of tissue from frontal sinus- Used for frontal sinus disease requiring exploration or tissue removal. May be performed in conjunction with
31237if multiple sinuses are involved.
- Used for frontal sinus disease requiring exploration or tissue removal. May be performed in conjunction with
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31287– Nasal/sinus endoscopy, surgical, with sphenoidotomy- Opening of the sphenoid sinus. Used when disease is present in the sphenoid sinus.
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31288– Nasal/sinus endoscopy, surgical; with removal of tissue from the sphenoid sinus- Removal of tissue from the sphenoid sinus. May be performed with or as an alternative to
31237for sphenoid sinus disease.
- Removal of tissue from the sphenoid sinus. May be performed with or as an alternative to
These codes are related to 31237 as they represent variations or extensions of surgical endoscopy procedures in different sinus regions. They may be used together in complex cases or as alternatives depending on the clinical scenario.
National Reimbursement Benchmarks
For CPT code 31237, the national mean rate for Medicare is $275.28, while the BUCA (average commercial) mean rate is $314.99. Commercial payers such as UnitedHealth Group and Cigna report higher mean rates, with UnitedHealth Group at $398.70 and Cigna at $375.26, compared to Medicare.
Rate dispersion, measured by the difference between the 75th and 25th percentiles, varies across payers. Medicare shows the tightest range at $27.00, indicating relatively consistent reimbursement rates. In contrast, UnitedHealth Group has the widest range at $214.64, reflecting greater variability in commercial payments. Cigna and BUCA also exhibit substantial dispersion, while Aetna and Blue Cross Blue Shield fall in the middle.
The table and chart below present a detailed breakdown of national benchmarks for each payer, including mean rates and percentile values.
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